Bill Levinson

That makes sense to me too, then. There is obviously a difference between polio patients and COVID-19 patients. It sounds like negative pressure will not expand the aveoli, then.

If hospital administrators are demanding that health care professionals work without adequate PPE, then perhaps they should set an example by accompanying doctors and nurses, while wearing whatever PPE is available to the doctors and nurses, while visiting patients who have coronavirus. If they believe the PPE is adequate then they should not have a problem with this. This is NOT something I would advocate from a strict safety perspective because exposing unnecessary people to the risk is counterproductive but, on the other hand, there is the military adage that a leader does not tell a follower to take a risk the leader will not take himself/herself. (Does not constitute engineering or OH&S advice.)

I am an engineer and not a health care professional, so I'd appreciate some feedback from people on the medical side. There is widespread concern about the shortage of ventilators, and also an observation that the ventilators themselves can cause damage (e.g. barotrauma, intubation-related infections). Are there reasons the much older, but proven (at least in the case of polio) iron lung technology cannot be used? It does not require intubation and is apparently less stressful on the lungs. https://newatlas.com/medical/british-engineers-modern-iron-lung-covid-19-ventilator-alternative/ "Unlike ventilators, the exovent doesn't require intubation and is much simpler in design and operation. According to the consortium responsible for its design, patients can remain awake, take medications, eat and drink, and talk to their loved ones on the phone. In addition, the machine improves heart efficiency by 25 percent over conventional ventilators, which can adversely affect cardiac functions." Also https://www.ncbi.nlm.nih.gov/pubmed/15065832 "This study suggests that iron lung ventilation is as effective as invasive mechanical ventilation in improving gas exchange in chronic obstructive pulmonary disease patients with acute respiratory failure, and is associated with a tendency towards a lower rate of major complications."

I am not in management but I think very poorly of a management team that forced you to use your vacation time to recover from an illness you apparently got while on the job. Also, it is conceivable that you could have a worker's compensation claim for COVID-19 acquired on the job; I can't give legal advice but here is an article on this subject. https://www.govtech.com/em/safety/Hospital-Workers-Getting-Coronavirus-on-the-job-as-Hospitals-Push-Back.html

I am not a health care professional and I don't know if this would work, but would there be circumstances under which people who have recovered from coronavirus be hired by hospitals to assist health care workers? The idea is that, if they are immune, they could work directly with patients (under close supervision by a licensed professional) to perform tasks that do not require specialized skills. They could also do things like move COVID-19 patients around without any danger to themselves or others (as they are immune and cannot carry the disease), handle laundry from COVID-19 patients, and so on. The basic idea is that we do have a large pool of people (maybe tens of thousands by now) who have had the disease and have recovered from it, and are therefore known to be immune to it.

My opinion (not legal advice, or formal engineering or OH&S advice) is that medical personnel who choose to work in a COVID-19 environment are going above and beyond the call of duty. With regard to employers who tell health care workers they cannot wear even their own PPE, however, https://www.osha.gov/right-to-refuse.html Workers' Right to Refuse Dangerous Work If you believe working conditions are unsafe or unhealthful, we recommend that you bring the conditions to your employer's attention, if possible. You may file a complaint with OSHA concerning a hazardous working condition at any time. However, you should not leave the worksite merely because you have filed a complaint. If the condition clearly presents a risk of death or serious physical harm, there is not sufficient time for OSHA to inspect, and, where possible, you have brought the condition to the attention of your employer, you may have a legal right to refuse to work in a situation in which you would be exposed to the hazard. (OSHA cannot enforce union contracts that give employees the right to refuse to work.) Your right to refuse to do a task is protected if all of the following conditions are met: Where possible, you have asked the employer to eliminate the danger, and the employer failed to do so; and You refused to work in "good faith." This means that you must genuinely believe that an imminent danger exists; and A reasonable person would agree that there is a real danger of death or serious injury; and There isn't enough time, due to the urgency of the hazard, to get it corrected through regular enforcement channels, such as requesting an OSHA inspection. You should take the following steps: Ask your employer to correct the hazard, or to assign other work; Tell your employer that you won't perform the work unless and until the hazard is corrected; and Remain at the worksite until ordered to leave by your employer. If your employer retaliates against you for refusing to perform the dangerous work, contact OSHA immediately. Complaints of retaliation must be made to OSHA within 30 days of the alleged reprisal. To contact OSHA call 1-800-321-OSHA (6742) and ask to be connected to your closest area office. No form is required to file a discrimination complaint, but you must call OSHA. ==================== An ethical issue arises here that does not exist in workplaces that are just making a product for money, as a health care provider's refusal to perform dangerous work means patients will not get the care they need. In addition, failure to provide adequate PPE is due to force majeure as opposed to an employer intentionally cutting corners or not caring about safety. My position is that all doctors, nurses, and others who risk exposure to this disease deserve enormous credit (and collectively, the nation's civilian counterpart of the Medal of Honor), but any hospital or other system that intentionally cuts corners, or tells people to not wear their own PPE if none else is available, should be reported to OSHA.

I think Oscar the Cat can tell by odor when somebody is going to die.

They ought to be able to train dogs to detect C-diff. Dogs can even detect certain forms of cancer (due to the trace odors exhaled by the patient) as well as diabetes. Well trained dogs could conceivably screen for some conditions, although of course you need a medical diagnosis to be sure. Using a dog's superior olfactory sensitivity to identify Clostridium difficile in stools and patients: proof of principle study | The BMJ

The initial decision to give CPR was correct because a living will takes effect only if the person is terminally ill. In other words, if somebody with a living will but no terminal illness collapses from a heart attack, CPR is given. The living will takes effect only if there is a condition such as incurable cancer that makes interventions futile, and serve at most to prolong the dying process. E.g. my father should not have been given CPR when his heart stopped, but he was suffering from a neurodegenerative disease (Lewy body disease). Unfortunately, none of his doctors had rendered a diagnosis to the effect that he had less than 6 months to live, so his living will never went into effect, and he did not receive hospice care from Medicare. (I did have a private duty nurse supplementing his care in the nursing home, but perhaps hospice could have done more for him.) In Pennsylvania, at least, a living will does not take effect unless its writer is diagnosed with a condition that is expected to be fatal within six months. This means that, if you don't want to be revived, it is important to get this diagnosis.

Maybe this is what Oscar the Cat smells.

I have heard that dogs can smell certain kinds of cancer. The cells doubtlessly emit a chemical that is not found in healthy tissue. I have never heard of a person being able to do it, though.

A Day in the Life of Oscar the Cat

Oscar the Cat is famous for being able to predict when somebody is going to die. It is quite possible that he smells some kind of biological change.

Ford would indeed have done this so fewer nurses could care for more patients--but without reducing quality by reducing the time that the nurses could spend with the patients. Suppose, for example, that proper care for a group of patients requires 30 minutes per patient per shift. A nurse who must walk for 2 hours out of every shift can care for 12 patients. If the nurse must walk only 30 minutes, he or she can care for 15 patients--and be paid 25 percent more. If the walking time can be put to productive use, however, this does not really apply. Ford never objected to paying good money for a good job, but he did not consider it fair to his customers or workers to hire, for example, ten people to do the work of five (because the job design wasted half of the worker's time). On the surface, this looks like jobs for five more people, but the bottom line is that five workers' pay must then be divided among ten people.

I am an industrial quality professional, and I am currently involved in a panel on health care reform. (I previously was part of Governor Rendell's health care reform panel, where he brought in doctors, business professionals, and so on to comment on health care reform efforts in Pennsylvania.) I have written several trade journal articles on the need to implement quality management systems (like ISO 9001:2000) in health care systems. A recent one in Patient Safety and Quality Healthcare says that hospitals should fix the root causes of mistakes--four out of five of which are the responsibility of the system in which health care workers must work, as opposed to negligence or carelessness--instead of disciplining nurses. The latter approach discourages nurses from reporting mistakes or even near-misses, which means the underlying problems never get corrected and the same mistakes can happen again. In a Japanese-run hospital, a nurse would immediately report that she had, for example, almost given somebody the wrong medication. The system in which she worked would be changed to make such an error impossible in the future. Not only would she not be disciplined, she might even be praised or rewarded for bringing the potential problem to management's attention. Japanese workers do this all the time. Shigeo Shingo said that any job that requires "worker vigilence" (e.g. "being careful") to prevent mistakes is not properly designed. 30 to 60 cents of every health care dollar is wasted on activities that do not create any benefit for patients. This includes things that hurt patients, like hospital-acquired infections. If this cost of poor quality could be reduced or eliminated, patients would have better outcomes and lower costs, while nurses and physicians could be paid more. The government's current health care "reform" plans do not even begin to address the costs of poor quality and inefficiencies in health care.

"Carrying" (transportation) is actually defined as a non-value-adding activity (waste) in lean manufacturing, e.g. if parts have to be moved from one part of the factory to another. The parts must obviously be moved to the work station, and the medications must obviously get to the patient, but the manner in which this is done defines the efficiency of the process. The idea of robotic carts to deliver medications from the pharmacy to the nurse's station came to mind immediately, and the FIRST item from a Google search on "robotic carts" yielded http://www.compukiss.com/articles/robotic-helpers-are-here-now.html " If you have been to the hospital lately, you might have seen robotic carts delivering medications and equipment." This is still transportation (non-value-adding activity), but I'm pretty sure the robot's time, in terms of capital investment and electricity, is far less valuable than that of a nurse or other human worker. If, however, value-adding work can be done while walking, such as assessing gaits, this is value-adding time and not waste. I am thinking more in terms, though, of nurses having to walk to and from patient rooms to supply areas, pharmacies, data entry stations, and so on. One objection that doctors have to computerized physician order entry (CPOE) systems is that they would have to walk to a computer to write a prescription as opposed to writing it on a pad. This is a valid objection because walking to and from the computer is waste. If the doctor has some kind of handheld device, it eliminates the need to walk. The same goes for entry of patient data (e.g. blood pressure and so on) by nurses; if you have to walk to a room to enter this information, it's wasted time. Here is an interesting question; do patient rooms have computer terminals or something similar into which nurses can enter this information, or are portable handheld devices available?

This is all excellent information, and I can use it in some articles I am writing about GENUINE health care reform. It confirms that the story I heard from a nurse a couple of weeks ago is not an isolated situation, and that the way nurses' jobs are designed includes enormous waste. Henry Ford wrote more than 80 years ago that people cannot be paid to walk. In your case, assuming that you can walk 3 miles an hour inside a hospital, you spend 3.3 to 4 hours per shift walking. You can be paid only to take care of patients, which means you are actually paid for fewer than 9 of the 12 hours you work. To put this another way, fewer than 9 hours of genuine pay are spread over 12 hours of work, like butter being spread too thinly on bread. (I don't eat butter because of the fat, but it shows the idea.)

A nurse told me that she wore a pedometer and discovered that she had to walk eight miles every day. At three miles an hour, that would come to 2.67 hours out of every eight that she works. Henry Ford said that pedestrianism is not a highly paying line of work, so he designed the Henry and Clara Ford Hospital to minimize the walking that nurses have to do. In the case shown above, the nurse is effectively paid for 5.33 hours of every eight that she works. If this could be corrected, we would not have a nursing shortage because nursing salaries could be increased 40 percent or more without higher costs for patients or insurers. Can anyone provide some information on how much walking he or she has to do every day?

Re: As far as I know, the initial decision to perform CPR was correct. A living will applies only if the patient is terminally ill or permanently unconscious. Some states prescribe a period of time in which death is expected to allow invocation of a living will. In Pennsylvania at least,http://www.aging.state.pa.us/aging/lib/aging/Advance_Directives_brochure1.pdf Since the woman in question was neither terminally ill nor permanently unconscious when she collapsed, paramedics would have attempted to revive her even with a living will right in front of them. On the other hand, it sounds like the living will should indeed have taken effect after the efforts in question failed to prevent irreversible and terminal brain damage.I went through a similar situation in which my father, who had Lewy Bodies' disease (per autopsy), stopped eating and drinking. I was going to have a feeding tube put in because I envisioned him being hungry and thirsty. (The subsequent Terry Schiavo case certainly reinforces this perception, although I understand that they would not offer her liquids by mouth either). Also, his living will said only that he wanted to refuse CPR and artificial ventilation, not artificial nourishment. (Perhaps fortunately) he died before I could act on the feeding tube. Furthermore, none of his doctors ever pronounced him terminally ill, so I am not sure I could have even refused CPR or ventilation on his behalf. One ER doctor (he was taken there after being unresponsive in the nursing home) asked whether I wanted anything done if his heart stopped, and I told him I had no idea because he had never been pronounced terminally ill as my state's living will law requires. Although in this case it sounds like a family member was indeed an obstacle to the patient's wishes, the doctors also have a responsibility to make it clear (in writing) their belief that heroic treatment will only prolong the dying process. This is a legal requirement in my state.

Furthermore, a culture of blame discourages health care workers from reporting near-miss situations, while the identification of a person to blame deflects attention from the underlying problems that caused the incident to happen. Considerable trouble, ill will, and malpractice litigation can be avoided when hospital administrators recognize that the system is responsible for most medical errors, encourage health care workers to identify deficiencies in the system, and implement closed loop corrective action (CLCA) to remedy them. In addition, many medical errors would probably be close to impossible in an ISO 9001:2000 compliant hospital. ISO 9001:2000 is an internationally recognized standard for quality management systems, and International Workshop Agreement IWA‑1 from the American Society for Quality and Automotive Industry Action Group is a health care specific modification. Where Do Problems Come From? It is a general rule in industry that only 15 to 20 percent of trouble comes from negligence, carelessness, and incompetence. The rest is due to deficient organizational systems that make trouble almost unavoidable. W. Edwards Deming's 85/15 rule says that 85 percent of all defects and errors are the fault of the system in which people must work, while 15 percent results from carelessness and negligence. Frank Gryna cites an 80:20 ratio, with 80 percent of errors and mistakes being "management-controllable" and only 20 being "worker-controllable." [1] The typical cause and effect diagram (also known as the fishbone diagram because of its shape, or the Ishikawa diagram after one of its principal exponents) displays six main categories of problem sources. It uses the mnemonic acronym 6M or "5Ms and E" to make them easy to remember. Machine (Equipment) Faulty or unsuitable equipment is a common source of trouble. In a hospital, equipment that is hard to sterilize or disinfect can transmit disease bacteria. Any equipment that relies on the health care worker's vigilance to prevent it from harming the patient should be considered unsuitable for the job. Jidoka (autonomation) means that the equipment can recognize abnormal conditions, and either correct those conditions or shut down and sound an alarm. One discussion thread in Allnurses.com [2] describes how a failure in an intravenous device's roller clamp delivered an hour's worth of potassium chloride in less than ten minutes, thus causing the patient's death. In contrast to gravity-fed equipment that can conceivably deliver unlimited or uncontrolled flow in the event of a valve or clamp failure, a pump cannot provide more flow than its electronic control system allows. A very quick Google search shows that the technology is available. The invention is concerned with controlling fluid delivery by a fluid dispensing system in which fluid is dispensed from a container, through a delivery tube, under the control of a flow controller or peristaltic pump and, particularly, with the control of the rate of fluid delivery to a patient by an intravenous infusion system utilizing a standard administration set. [3] Again, if the equipment must rely on the nurse's vigilance to make sure it does not harm or kill the patient, it is probably not suitable for the job. Method (the procedure for the job) If a nurse gives a patient the wrong medication or the wrong dose because she didn't understand the doctor's verbal instruction, who is at fault? The answer is probably the lack of a verbal order read back procedure, in which the nurse repeats back to the doctor what she thought she heard. If the hospital administrators blame a person instead of the procedure, it is only a matter of time until the same thing happens again. Manpower (personnel; the gender-specific term allows the 6M acronym). Assignment of inadequately trained personnel to a job would fall into this category. The ISO 9001:2000 quality system standard requires the organization to demonstrate how it ensures that people are qualified for the jobs to which it assigns them. Inadequate staffing--for which management is ultimately responsible--is another personnel issue. "We didn't have enough people to perform all the quality checks" is never accepted as an excuse when a supplier delivers faulty products to a customer, and inadequate staffing should be even less excusable in a hospital or nursing home. Measurements In a hospital, these include testing and diagnostic equipment. Materials (consumable items) In health care, these include medications, antiseptics, dressings, and so on. The typical difference between a machine and a material is that the former is durable while the latter is consumable. However, a single-use piece of equipment like a disposable syringe would probably be classified as equipment rather than material. Environment or Medium (the environment in which the job is performed) In factories, temperature and humidity are usually the chief considerations. In hospitals, these factors affect patient and staff comfort, while disease bacteria become yet another factor. As an example, door handles can harbor methicillin resistant staphylococcus aureus (MRSA), and transfer it from one person's hands to another. The new Royal Liverpool Hospital in England may have silver, or more likely silver-plated, door handles [4]. Silver forms a very thin oxide layer upon exposure to air, and it is fatal to disease bacteria. Problems may, of course, result from a combination of these six factors. Inadequate disinfection of colonoscopies shows how a combination of new equipment with lack of awareness of updated instructions exposed patients to potential harm: The problem with the improperly disinfected Forbes colonoscopes was an extra water jet inside updated instruments bought by the hospital last fall from New York-based Olympus America Inc. Two years ago, the U.S. Food and Drug Administration published a safety alert cautioning hospitals to clean and disinfect this auxiliary channel after every colonoscopy. The warning was issued in response to reports of some hospitals not cleaning the jet because they didn't know it was there or because they didn't use it. [5] The reference adds that a biomedical engineer published a paper about this in the widely read Gastroenterology Nursing journal, but that problems like this keep recurring. The reason is probably that not everybody reads the journal, and that the people who disinfect the colonoscopes don't bother to read the new instruction manuals. The new colonoscopes probably looked a lot like the old ones, and the people whose job it was to disinfect them had no real reason to believe that the new items needed a different procedure. An ISO 9001:2000-compliant quality management system does not assume that anybody reads new instructions, trade journals, FDA safety alerts, or anything else. It ensures that the people read the new instructions by informing them of the change, and then requiring them to sign a log to verify that they had read the new procedure. Closed Loop Corrective Action Placing blame on the nurse (or doctor) for a system-related deficiency is worse than unfair to the health care worker and detrimental to overall morale. It also allows the deficiency to go uncorrected, thus placing future patients at risk. In industry, any serious quality problem requires closed loop corrective action (CLCA) to make sure it does not happen again. Numerous methods like the Ford Motor Company's Team Oriented Problem Solving, Eight Disciplines (TOPS‑8D), and Six Sigma's Define, Measure, Analyze, Improve, and Control (DMAIC) are available. All operate in essentially the same manner, though. All modern CLCA approaches involve a cross-functional team of people with relevant skills. As an example, a doctor, nurse, and pharmacist might participate in a team to assess medication errors. This is because the doctor issues the prescription, the pharmacist fills it, and the nurse administers it. The three tasks are interdependent, so any solution must involve them all. The team must define the problem clearly, identify the problem's root cause, and then develop a corrective action to fix that root cause. The corrective action is then tested for effectiveness and, if successful, it becomes the new standard for the job. Standardization is mandatory, and this is why ISO 9001:2000 is so obsessed with "documentation." If the organization relies on word of mouth, or postings on bulletin boards, some people will do the job the new way while others will do it as they have always done it. Obsolete work instructions must be withdrawn, and everybody who does the job must confirm that they have read the new work instruction. Since mistakes in health care settings can endanger people's lives, the system must empower and encourage everyone--including doctors, nurses, and even patients--to report anything that could conceivably lead to trouble. The hiyari or "scare report" is a vehicle for doing this. The Hiyari or "Scare Report" Japanese factories use a document known as a hiyari or "scare report" to report near-misses, as does the Inoue Hospital in Osaka, Japan [6]. Any mistake that is caught through "worker vigilance" is treated as if it had actually happened, and closed loop corrective action is taken to prevent any recurrences. Suppose, for example, that someone finds an oxygen tube on the floor where it could conceivably be stepped on, or rolled on by a patient's chair, thus restricting or cutting off the gas flow. Whoever finds this should file a hiyari, and the problem treated as if it had actually happened. Furthermore, meetings or bulletin board postings that tell nurses to "be more careful" about letting the tubes fall on the floor are emphatically not a satisfactory solution. First, no solution that requires worker vigilance is really a good one. Second, there are doubtlessly other ways in which flexible tubes can become fouled or constricted. The solution should consider, for example, monitors that detect unusual gas pressures (thus indicating blockage in the tubes). This is an example of jidoka or autonomation; the equipment is capable of sensing abnormal conditions, and of sounding an alarm when they occur. The Allnurses discussion board [2] cites numerous examples of different medications whose containers look alike, or whose names sound alike. This is a perfect example of a case for a hiyari. The author recalls a self-directed work team in a factory that noticed that process recipes differed by only one digit, thus making it easy to enter the wrong one by mistake. The team's solution was to change the numbering scheme to make the recipes' numbers very different. While a hospital can't change the names of medications, it can implement a computer physician order entry system (CPOE) and bar codes for medication containers. Another example would be a situation in which a nurse warns a doctor that the dosage he is prescribing is unusual or dangerous. A culture of blame would promote animosity, because the doctor doesn't want anyone to know that he endangered the patient, while the nurse might have gotten into trouble for administering the overdose. While the doctor is ultimately responsible for the decision, common sense says that he or she cannot rely on memory for the proper dosages, and also that many medications have similar names. A CPOE system would probably be of great comfort to everybody. It would immediately tell the doctor if the dose was outside the usual range, and also if the medication interacted with the patient's other medications. The key point is, however, that a culture of blame would create a very tense situation between the doctor and the nurse. In an intelligently-managed environment, the doctor himself might file a hiyari that said, "I almost prescribed the wrong dose, and only the nurse's vigilance prevented it." The doctor is not "taking the blame" by doing this, he is pointing out just how easy it is for every doctor in the hospital to make this kind of error. The result should be a systematic change that makes the error as close to impossible as is practical. Summary At least four out of five medical errors are probably due not to negligence or carelessness, but to deficiencies in the system in which doctors and nurses must work. The ISO 9001:2000 standard and its health care specific modification, IWA‑1, recognize that people work in a system, and that a deficient system cannot deliver good quality no matter how skilled or careful the workers might be. Elimination of medical errors requires closed loop corrective action for all occurrences, with near-misses being treated as if they had actually occurred. The organization's culture must encourage the identification of problems and closed loop corrective action. A culture of blame serves only to (1) discourage people from reporting problems and (2) deflect attention from the problems' root causes. Disclaimer Nothing in this article constitutes medical advice, which the author is not qualified to give, nor does it constitute engineering advice. Discussions are based entirely on information from the indicated references, and not on first-hand knowledge. References [1] Juran, Joseph, and Gryna, Frank. 1988. Juran's Quality Control Handbook, 4th ED. New York: McGraw-Hill, 17.4-17.5 [2] "7000 fatal med errors last year-where are theses nurses?" http://allnurses.com/forums/f8/7000-fatal-med-errors-last-year-where-theses-nurses-171356.html [3]Wheeldon; Peter G. (Guildford, GB2), Kent; John (Nr. Petworth, GB2) U.S. Patent4,670,007 [4] Bartlett, David. 2007. " Blueprint for new Royal Liverpool Hospital unveiled." Liverpool Daily Post, July 24, 2007. Liverpool Echo: Latest Liverpool and Merseyside news, sports and what's on [5] Bails, Jennifer. 2005. "Candor praised in scope problems." Pittsburgh Tribune Review, April 1 2005. [6] Imai, Masaaki. 1997. Gemba Kaizen: A Commonsense, Low-Cost Approach to Management. New York: McGraw-Hill pp. 142-143, 273-276

This is interesting http://www.ismp.org/Newsletters/acutecare/articles/20071115.asp "Errors with injectable medications: Unlabeled syringes are surprisingly common!" Anyone who has worked in a factory knows that you NEVER use anything from an unlabeled container. The recommendations in the article make perfect sense.

This is why I have ZERO sympathy for health care providers that want legislative caps on malpractice damages. The financial consequences of cutting corners (e.g. by understaffing) have to be far worse than the cost of maintaining adequate staffing. This, apparently, is the only thing that many managers understand.

The people for whom I have no respect are hospital administrators and executives who create bad systems and then discipline the nurses when inevitable problems result. If a nurse (or medical intern/resident) makes a "mistake" because she has been forced to work for sixteen straight hours because the hospital administrators didn't hire enough people, my inclination would be to fire the administrators and not the nurse/intern. The administrators are responsible for making sure there is adequate staff, and anyone with any brains knows that you don't make anyone do a life-critical job (e.g. fly a passenger airplane, drive a 30-ton truck on a public highway) when they are exhausted, unless there is a genuine emergency like a war or a disaster in which there is no choice.

i would never dream of telling a md, rn, or lpn how to do his or her job. since i have considerable experience and several professional certifications in the quality management field, however, i am probably more qualified than most medical professionals or hospital administrators to talk about how the system in which medical professionals must work should be designed. if you show me five malpractice cases (or so-called "nurse errors"), i can show on average how four of them would have been prevented by a decent quality management system. there is a huge difference between telling a doctor or nurse how to do his/her job and designing systems so they can do their jobs without being tripped up by the system itself.

I've never seen a PCA pump but a relatively-obvious solution comes to mind. I assume there is some kind of fixture through which the syringe is attached to the pump. The syringe's front could conceivably be equipped with a key or slot-- one kind for Dilaudid and the other for morphine. A morphine syringe should not fit a Dilaudid container and vice versa. In other words, if the pharmacist tries to fill a morphine syringe (meant for the PCA pump) with Dilaudid, he will immediately see that it won't go into the medication bottle. Furthermore, the syringe key or slot will tell the PCA pump what kind of medication is being used. The idea comes from industry. A gas valve for an oxygen line won't fit a hydrogen tank, and vice versa. The idea is to make it impossible to blow yourself (and the factory) up by connecting oxygen to a hydrogen system, or vice versa. Henry Ford's principle was, "Can't, not don't." Instead of posting signs that tell workers, "Don't put your hands in the machine," you design the machine so the worker CAN'T put his hand in the machine. As an example, mechanical presses require the operator to press two switches, so the machine "knows" where its operator's hands are before it comes down with several thousand pounds of force. Anyway, the PCA should (ideally) be designed so you can't put the wrong medication in, or so the device will "know" for certain what kind of medication is present. Another thought is as follows. I don't know how far infrared chemical analyzers have progressed since I was a chemistry student, but it might be possible to install them in PCA pumps (or other IV devices) so the device itself can check the identity of the medication that is being used. The incidents you are describing simply reinforce my opinion that 80-85% of all "malpractice" (and "nursing errors") come from the system in which the medical personnel must work as opposed to behaviors for which anyone should be sued or disciplined. The hospital administrators are responsible for the systems and, if the systems end up harming patients, that is where the blame should fall.