Second Lawsuit Filed In Hydraulic Fluid Mistake At Hospitals

    0
    1

    WRAL.com

    I've talked a little about using lean to prevent medical mistakes. This mistake, someone using hydraulic fluid to clean surgical instruments, is mind boggling. It mekes you wonder if the bottle/can of hydraulic fluid was in a bottle that looked visually very similar to the cleaning solution bottle/can? Like we need more worries about a hospital visit.

    Off the top of my head, it seems like they could either store/repackage cleaning solutions in visually obvious bottles even if it's not the OEM bottle (“blue bottles” are for cleaning solutions) or make sure non-cleaning solutions are not stored anywhere near cleaning solutions. Simple visual management and 5S tools could be used to prevent this, maybe combined with better standard work and training.

    Either way, it seems like it would help to have a network of hospitals to communicate errors like this — once an error like this happens, it would be nice to see ALL hospitals take proactive corrective actions to prevent this same failure mode from ever happening again.

    Please check out my main blog page at www.leanblog.org

    The RSS feed content you are reading is copyrighted by the author, Mark Graban.

    , , , on the author's copyright.


    What do you think? Please scroll down (or click) to post a comment. Or please share the post with your thoughts on LinkedIn – and follow me or connect with me there.

    Did you like this post? Make sure you don't miss a post or podcast — Subscribe to get notified about posts via email daily or weekly.


    Check out my latest book, The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation:

    Get New Posts Sent To You

    Select list(s):
    Previous articleToyota and the “Thinking Production System”
    Next articleLean Training through Iowa Community Colleges
    Mark Graban
    Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.

    1 COMMENT

    LEAVE A REPLY

    Please enter your comment!
    Please enter your name here

    This site uses Akismet to reduce spam. Learn how your comment data is processed.