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  • Failed attempt to improve a decision process in pediatric cardiac service [Elektronski vir] : dysfunctional organizational and safety culture
    Robida, Andrej
    This case report describes how a deficient organizational structure can impact patient safety and burden the intensive care resources. A pediatric cardiologist and a fellow pediatric cardiac surgeon ... decided to complete a bilateral pulmonary artery banding and proceed with prolonged prostaglandin infusion on a 2-dayold infant with hypoplastic left heart syndrome after a telephone consultation with a foreign senior pediatric cardiac surgeon. Another senior pediatric cardiologist did not agree with the proposed plan due to a lack of experience of a domestic surgeon in training and paucity of experience of physicians in the intensive care unit with prolonged prostaglandin infusions. As the organizational matrix deferred to the decision of the cardiac surgeon, the infant surgery was done. Unfortunately, the banding procedure was unsuccessful, and the infant then underwent a Norwood procedure. Six weeks later, the infant died suddenly during a routine chest X-ray examination. The cause of death was heart failure. An audit commission was arranged. Their report determined several systemic flaws in the pediatric unit; however, the hospital chose to publicly discredit its audit commission rather than make adjustments in response to the findings.
    Vir: Austin critical care case reports [Elektronski vir]. - ISSN 2768-5500 (Vol. 3, iss 1, [article no.] 1014, 2019, str. 1-2)
    Vrsta gradiva - e-članek ; neleposlovje za odrasle
    Leto - 2019
    Jezik - angleški
    COBISS.SI-ID - 170722819

    Povezava(-e):

    https://austinpublishinggroup.com/critical-care-case-reports/fulltext/criticalcarecr-v3-id1014.pdf

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