Edmonton dialysis - terrifying

[justagirl2325]

A Canadian health-law expert says police should investigate a dialysis patient's death, but authorities in Alberta seem confused over who can make that decision.

"It's beyond obvious that someone was negligent, maybe even criminally negligent," said Amir Attaran, an associate professor in the University of Ottawa's Faculty of Law with a specialization in population health.

The water used to clean the blood of four dialysis patients at the Royal Alexandra Hospital was contaminated with powerful cleaning agents on Friday.

Alberta Health Services admitted a contract worker from Atek Water Systems mistakenly opened the wrong valve and flushed the chemicals into four dialysis machines hooked up to individual patients.

Three of those patients remain in stable condition in hospital. A fourth, a man whose identity has not been released, died two days after the mistake.

[Michael Murphy]

This is stupid.  They were pouring acid and peroxide into part of the water system while patients were attached to the machines.  While not a medical professional I was responsible for the day to day operations of the computers that ran one of the biggest telecom phone networks in the U.S. .  If Amy one even touched the equipment during peak usage times they would have been terminated on the spot.  Letting anyone do this with live people attached is simply the most ignorant thing I can imagine.  People make mistakes turning the wrong valve is  easy todo letting some work on equipment that supports living humans is beyond belief arrogant.  There is no reason this could not be done during the wee hours of the morning when no one is hooked up.  Doing it during the day is either to save money or some lazy person wants to work during the day.

[Simon Dog]

There is no reason this could not be done during the wee hours of the morning when no one is hooked up.  Doing it during the day is either to save money or some lazy person wants to work during the day.

You said there was no reason, the offered two possible reasons   

[Michael Murphy]

Tat should have read no sane resonable reason.  The two I mentioned but staff and budgeting ahead of patient well being.

[Simon Dog]

staff and budgeting ahead of patient well being.

And in other news, water is wet and polar bears are still white.

[Michael Murphy]

That may be but I still find this action by a provider both stupid and thoughtless.  If the equipment is important don't mess with it when it is in use.  I don't care how well meaning these people are they did not put the wellfare of the patients above that of their schedule and wallet.  I don't blame the tech but the manager of the site who authorized the work while the system was servicing patients has three sick patients and one dead body on his or her head.

[Simon Dog]

I don't blame the tech but the manager of the site who authorized the work while the system was servicing patients has thee sick patients and one dead body on his or her head.

It's probably an issue of the incentives under which the manager of the site is operating.   If corporate HQ reacts favorably to a memo like "Overtime was authorized to remove a very small risk to patient safety", such things will happen.   If HQ is only concerned with the bottom line, and bases the facility managers bonuses, job retention and promotion prospects only on the bottom line, such shortcuts will continue.    In other words, a fish rots from the head down.

It also helps if you have a medical director who won't tolerate shortcuts to safety to safe $$.  Basically you need a neph who is comfortable with the few hundred $K (s)he earns, and isn't concerned about squeezing more $ out of the clinic.

[Michael Murphy]

Worse this is ran by Alberta medical which appears to be a province organization.  I am not sure of Canadian tort laws in the u.s. The payout for a suit would be enormous.  My bottom line is that people who manage technology also must manage risk.  And any risk that end with a patient dead is risk to avoid.

[Simon Dog]

And any risk that end with a pstient died is risk to avoid.

There are certain risk in the medical business that are unvoidable (for example, rare side effects to essential drugs).

But, there are other events the medical profession calls "never events" - as in should NEVER happen.  (for example, wrong side surgery).   Sounds like that clinic had a major "never" event.