Case Study: In Search Of The Lost Cord
The story is about a four-year old girl who was born with several birth defects. The Children’s Hospital management in Seattle worked hard to provide the best possible care that they could for the child. The hospital management assigned Karen who is a nurse to take care of the child whose condition is being monitored on machine with EKG electrodes which is taped to child chest. Karen was assigned her required task to reconnect the heart monitor cord to the lead from the electrodes on the child. However, Karen made a huge mistake because her awareness and attention was not at its peak. She mistakenly reconnected the wrong cord which was enough to cause the death of the child.
During the process of connecting the system, Karen lined up both ends and connected the cord with the connector. She didn’t know at that time that the cord she had was for the intravenous pump beside her, not for the heart monitor. When Karen connected the two cords it sent a current of electricity straight to the child chest causing her heart to stop responding. Karen immediately disconnected the cords but it was already too late. This small mistake had costs the child’s life. Although the cord she was attempting to plug in was a different shape than the average connectors since the intravenous pump was a specific model it had this same shape as well. After all, Karen uses different machines every single day to perform her regular job. Machines were designed to have different types of connectors to make it easy for users to distinguish between connectors. Indeed, these unique connectors made it easier to find the right pieces that supposed to fit together. More important, it made it nearly impossible to connect two things that were never meant to be connected. Karen had no means of knowing that the cord in her right hand was a live electrical voltage and that it carried the full operating current of the pump. The reaction was immediate, she quickly separated the two cords within a moment of realizing what had happened. Karen and other members of the staff administered cardiopulmonary resuscitation to the child, but they could not save her life. This is an avoidable mistake that was stated as a “human error” by a hospital spokesman.
To avoid this human error, I suggest that the hospital staff should have labeled the connections to make it easy for nurses to distinguish between cords under work stress. In addition, Karen should check the origin of the cord before making the connections for her to take significant actions to save people’s life. Moreover, the manufacturer should take extra precautions when they make cords, machines, and medical devices that we use in hospitals even if the nurses and doctors have an eye for details.
Finally, I recommend that hospitals should improve their training programs in using new technologies with vigilance, care, and knowledge to prevent lack of human care and caution when dealing with advanced technologies. As a result, I am sure that precautions have now been put into place; but the situation highlights the potential for other problems to arise as technology continues to grow even more complex and diverse around us.
