Page 38 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company
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Develop and implement an effec-
Failure of hospital quality assur-
Unnecessary amputation and tive patient accountability and ance process quality assurance process death Liability claims Damage to reputation and image The Improvement Challenge 17
cloud in the reactor building. The cloud contacted an ignition source and an explosion occurred. During surgery to amputate one leg of a diabetic, doctors mistak- enly removed the left leg instead of the right. Correction left the patient a double amputee.
Florida USA 1995 (48)
