The Pediatric Cardiac Surgery Inquest Report



Error, accident and humanity

Pediatric cardiac surgical procedures are planned and performed by human beings. The hospitals in which those procedures are carried out are designed and built by human beings. They design, manufacture, and maintain all the equipment used in the diagnosis of patients, and in their anaesthetic, surgical and intensive care. Human beings decide if a child will or will not undergo pediatric cardiac surgery. Human beings, as a team, provide the child's pre-operative, intra-operative and post-operative care.

Human beings make errors. We make errors in the design and construction of systems. (A system is defined as a grouping of inter-related components, which interact within a working environment to produce an outcome.) Thus, the health-care system represents everything from patients, personnel, the equipment and the environment within which care is provided, the organizations that provide that care, and the regulatory agencies, such as the government, that legislate or otherwise regulate the provision of health care.

We make errors in the design and construction of technology used in the system, and we make errors when we maintain those technologies. We make errors when we plan and when we execute plans. We make errors when we execute individual tasks that are part of a larger plan. We make errors through ignoring rules, misapplying rules, forgetting to execute part of our plan, and failing to execute plans properly. All errors and problems in a hospital, such as surgical complications, are related to human activity. Error is a human reality.

It is completely appropriate to strive to eliminate error or reduce the frequency at which errors are made. It is, however, unrealistic to believe that human error can be totally eliminated. More importantly, it is impossible to design a system that relies totally on everyone doing the tasks assigned to them properly. Allowances must be made for the possibility that errors will be committed and mechanisms to address that possibility must be put into place.

It is important, therefore, to set out how human error in a medical setting ought to be addressed by the hospital.



Current Home - Table of Contents - Chapter 10 - Error, accident and humanity
Next Dealing with human error
Previous Human and Medical Error
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
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