WEBVTT 1 00:00:15.800 --> 00:00:22.480 The hospital is a large complex organization with many employees representing a variety 2 00:00:22.480 --> 00:00:23.520 of occupations. 3 00:00:24.660 --> 00:00:27.780 Many of these have jobs which don't ever bring them to patient areas. 4 00:00:28.420 --> 00:00:33.480 Yet all of the effort and organization are ultimately directed to the individual patient. 5 00:00:34.400 --> 00:00:39.740 In a hospital, there can be no inspectors at the end of the assembly line to reject errors. 6 00:00:40.600 --> 00:00:44.380 Rather there must be constant vigilance to avoid error. 7 00:01:27.040 --> 00:01:27.460 The hospital is a large complex organization with many employees representing a variety 8 00:01:27.460 --> 00:01:27.460 9 00:01:27.460 --> 00:01:27.460 10 00:01:38.900 --> 00:01:44.620 With modern medical practice has come the introduction of a variety of specialized equipment, 11 00:01:45.220 --> 00:01:47.140 all requiring knowledge and efficiency. 12 00:01:48.160 --> 00:01:52.500 However, all of this apparatus requires more human judgment rather than less. 13 00:01:53.380 --> 00:01:58.640 Not only must one decide what is to be used and when, but there must be constant attention 14 00:01:58.640 --> 00:02:00.820 to adjustment and maintenance. 15 00:02:11.620 --> 00:02:14.200 Machines are no better than the humans who operate them. 16 00:02:14.600 --> 00:02:18.100 Minor adjustments may be of great importance to the patient. 17 00:02:18.900 --> 00:02:20.340 It all happened so suddenly. 18 00:02:20.380 --> 00:02:22.840 He was well, happy, playing in men's illness. 19 00:02:23.060 --> 00:02:24.400 Oh, please let him be well. 20 00:02:24.500 --> 00:02:25.200 Help him. 21 00:02:25.300 --> 00:02:26.280 Don't let him die. 22 00:02:26.580 --> 00:02:27.680 What are they talking about? 23 00:02:27.760 --> 00:02:29.160 Why doesn't somebody do something? 24 00:02:29.360 --> 00:02:30.520 Do they know what they're doing? 25 00:02:39.620 --> 00:02:42.320 A column of mercury reflecting the blood pressure. 26 00:02:43.080 --> 00:02:47.480 Even this relatively simple apparatus requires care and training to be used properly. 27 00:02:48.100 --> 00:02:50.820 An important decision may depend upon the readings obtained. 28 00:02:51.680 --> 00:02:52.540 Are they accurate? 29 00:03:00.240 --> 00:03:06.160 A case is discussed at length, defending the pros and cons of various procedures. 30 00:03:08.200 --> 00:03:12.820 The decision to administer a drug to a patient is followed by a complex chain of events. 31 00:03:13.500 --> 00:03:17.200 We must never allow any link in that chain to be broken. 32 00:03:36.720 --> 00:03:39.360 In a hospital, everyone is busy. 33 00:03:40.020 --> 00:03:41.360 Is he writing the order correctly? 34 00:03:42.000 --> 00:03:42.520 Should he check? 35 00:03:43.200 --> 00:03:47.260 Can routine become so commonplace that a mistake can creep in? 36 00:04:00.560 --> 00:04:04.280 The doctor does discover an error and corrects it. 37 00:04:04.580 --> 00:04:06.900 Perhaps the wrong dose could have been fatal. 38 00:04:19.320 --> 00:04:23.480 The nurse has an enormous job copying and recopying. 39 00:04:24.060 --> 00:04:26.980 Each step provides the opportunity for mistakes. 40 00:04:27.560 --> 00:04:29.940 There must be no letup in attendance to details. 41 00:04:30.800 --> 00:04:33.780 Each procedure must be rechecked constantly. 42 00:04:59.060 --> 00:05:00.920 How important is it to hurry? 43 00:05:01.600 --> 00:05:04.540 Does the patient's life hinge on the piece of paper she carries? 44 00:05:18.540 --> 00:05:22.620 The pharmacy has hundreds of drugs for a variety of purposes. 45 00:05:23.280 --> 00:05:25.360 Accuracy is of obvious importance. 46 00:05:25.900 --> 00:05:28.860 It is never acceptable to perform a task casually. 47 00:05:29.840 --> 00:05:32.600 Errors will occur unless there is constant attention. 48 00:05:38.380 --> 00:05:43.420 As the links in the chain are forged, it is clear that each must be sound. 49 00:05:44.140 --> 00:05:48.200 One defective link will destroy the whole chain. 50 00:06:03.860 --> 00:06:09.200 Memory is not to be trusted, not when the mission is so important. 51 00:06:25.320 --> 00:06:31.960 With this medication, one person checks the other as an added precaution against error. 52 00:06:42.660 --> 00:06:47.140 Preparing the medication is a long process, even boring at times. 53 00:06:47.860 --> 00:06:52.980 This is a tempting situation, particularly when rushed and two people are required. 54 00:07:09.460 --> 00:07:13.680 The precise dose is always of critical importance. 55 00:07:17.940 --> 00:07:21.800 There are so many steps that there may be temptation to cut corners. 56 00:07:21.800 --> 00:07:26.200 Each step is vital, contributing to the whole procedure. 57 00:07:53.580 --> 00:07:55.760 I'm going to sack it for a while, okay? 58 00:07:59.720 --> 00:08:01.020 Was everything done correctly? 59 00:08:01.520 --> 00:08:03.780 Wait a minute, what order did I write? 60 00:08:12.600 --> 00:08:15.280 Oh no, I forgot to check. 61 00:08:29.120 --> 00:08:32.780 It's not cc's, it's milligrams. 62 00:08:34.500 --> 00:08:36.400 How can I be sure? 63 00:08:41.640 --> 00:08:45.400 Go back, pick up the prescription. 64 00:09:01.260 --> 00:09:04.340 Don't, you took the wrong bag. 65 00:09:04.340 --> 00:09:07.840 Did everything go wrong? 66 00:09:32.720 --> 00:09:36.340 No, no, that's the wrong ampule. 67 00:09:54.420 --> 00:09:57.680 Don't spill it, the child needs all of it. 68 00:10:10.060 --> 00:10:11.180 What happened? 69 00:10:12.700 --> 00:10:14.920 I just don't know, I'm sorry. 70 00:10:27.700 --> 00:10:29.480 Oh my God, I better go check. 71 00:10:42.680 --> 00:10:44.500 He's doing much better, don't worry. 72 00:10:44.580 --> 00:10:45.420 I'll check. 73 00:11:12.140 --> 00:11:13.660 Thank you for everything. 74 00:11:13.840 --> 00:11:14.900 That's all right, okay. 75 00:11:18.140 --> 00:11:21.180 But it's never happened to you, to your knowledge. 76 00:11:22.300 --> 00:11:24.140 What will happen tomorrow? 77 00:11:24.860 --> 00:11:28.980 Hundreds of chains in the midst of tension, crisis, and overwork. 78 00:11:29.820 --> 00:11:31.480 Will they each be intact?