Health Care Safety at National Scale (PDF Presentation, 2008)
Health Care Safety at National Scale (PDF Presentation, 2008)
Health Care Safety at National Scale (PDF Presentation, 2008)
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Complex Cardiac Surgery:<br />
A Case Study of Playing with Fire<br />
• “Miraculous” mitral valvuloplasty<br />
• Transition home:<br />
– Extreme difficulty rising from bed<br />
– Lost five kilograms in 24 hours<br />
– “Lasix” to “furosamide” not understood<br />
– No instructions to discontinue Lasix<br />
– No inform<strong>at</strong>ion to primary care doctor<br />
– Surgeon: “I did my job; now it’s up to you.”<br />
The Cause: ?<br />
7
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