Page 39 - Serious Incident Prevention How to Achieve and Sustain Accident-Free Operations in Your Plant or Company
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The Improvement Challenge 17
Develop and implement an effec- tive patient accountability and quality assurance process
Failure of hospital quality assur- ance process
Unnecessary amputation and death Liability claims Damage to reputation and image
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)
