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20. Patient death or serious disability associated with an electric shock or electrical cardioversion in a health care facility
There are two standards that will prevent most deaths related to correcting lethal heart rhythms with electric shock. The first is that the type of electric shock delivery must be appropriate to the diagnosis. The second is that the equipment must be in good repair. For example, defibrillation is only appropriate for ventricular fibrillation. If the doctor misapplies it the patient will go into cardiac arrest. If the machine does not deliver the right amount of electricity (measures in Joules) the patient will likely die. There are no exceptions and no room for error. Additionally, cardioversion is even trickier because the shock has to be delivered at a certain point during the heartbeat. For this the doctor must rely on the equipment to work properly.
21. Any incident in which an oxygen line (or other type of gas) contains the wrong gas or is contaminated by toxic substances
It’s difficult to believe that such mishaps would occur on a regular basis. There must be basic engineering protocols that establish that only qualified technicians would have access to the source of gases administered in a health care facility. There must also be mandates for frequent safety inspections both at the source and at all of the points of delivery. Patient rooms should not have any gas other than oxygen. Other types of gases are only administered by anesthesiologists or nurse anesthetists. The multiline devices that they use must be checked for safety before each use to make certain that the different gas lines are correctly color coded and labeled.
