I'm a big fan of procedures designed to reduce the chance for mistake ...
... but at the end of the day, mistakes will happen no matter what procedures you put in place and no matter how stringently you try to get people to adhere to them. It's life. Assuming it's not a pattern of mistakes with similar causes, how you respond says more about you than the mistake itself.
The only pop-off valve death I personally know of happened at a clinic that by all accounts did/does everything right. They aren't a fly-by-night place with no monitoring on their patients trying to have a tech do anesthesia and dentistry all alone while simultaneously monitoring all the other post-ops, etc. It's a place that has a tech dedicated to monitoring the anesthetized patient who is by protocol not allowed to leave that patient. Another tech to do the initial dental work and rads. Rules about pop-off valves always being left open 100% of the time. All the right protocol, etc. And all it took for them one day is for the monitoring tech to be in surgery prior to the doctor arriving (1), and for her hear a major huge commotion in the room outside .... and so she left her patient to help out (2). And happened to just have screwed down the pop-off valve and got distracted by the commotion (3). Three pretty distinct things that, had any of them not happened, the chain would have been broken.
*shrug* Protocol and procedures are worth it to minimize error, but nothing completely overcomes our innate ability to screw things up.
I'm fascinated by human error. I think it comes from my flying days, where accident chains are analyzed to frickin' death. The biggest lesson is that assuming the right protocol is in place, it's rarely one single mistake that kills a patient. It's usually a chain of errors or circumstances with multiple opportunities to head off the end result.
A classic, fantastic example is http://ift.tt/12V3zYH. Just read the first paragraph and it gives you the gist of it. A perfectly flyable airplane with a relatively insignificant problem flown into the ground by well-trained, experienced crew. All the protocol in the world, but a few circumstantial things and some distraction and a horrible outcome.
Same accident chains happen in vet med.
I had a NE tube accident once as a student tech. The very experienced critical care tech and I put an NE tube in. I put a little sterile water in and didn't get a cough, but I forgot to check suction. Took the patient off for placement rads. The placement rads were read out together by an intern and a resident, but they got distracted talking about something else in the thorax they noticed on the rads, and didn't really evaluate the tube placement like they were supposed to and signed off on it. Next morning that patient had a raging pneumonia from the clinicare that got put in its lungs. (On the fortunate side, it recovered.)
But just ... yanno ... look at all the things that had to go wrong. The tube had to go down the trachea. That's not really a "mistake" in that hey - you put them in and they <should> go down the esophagus but they don't always. It's not really "fault" per se. But it's an abnormal circumstance (1). I forgot to check suction (2). The patient didn't cough with administration of water, even though most of them will (3). The intern/resident got distracted reading out the rads and missed their chance to catch the problem (4).
Most 'mistakes' have multiple chain-breaking moments like that......
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What happens when you mess up BADLY?
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