Chain, The

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The hospital is a large complex organization with many employees representing a variety of occupations.

Many of these have jobs which don't ever bring them to patient areas.

Yet all of the effort and organization are ultimately directed to the individual patient.

In a hospital, there can be no inspectors at the end of the assembly line to reject errors.

Rather there must be constant vigilance to avoid error.

The hospital is a large complex organization with many employees representing a variety With modern medical practice has come the introduction of a variety of specialized equipment, all requiring knowledge and efficiency.

However, all of this apparatus requires more human judgment rather than less.

Not only must one decide what is to be used and when, but there must be constant attention to adjustment and maintenance.

Machines are no better than the humans who operate them.

Minor adjustments may be of great importance to the patient.

It all happened so suddenly.

He was well, happy, playing in men's illness.

Oh, please let him be well.

Don't let him die.

What are they talking about? Why doesn't somebody do something? Do they know what they're doing? A column of mercury reflecting the blood pressure.

Even this relatively simple apparatus requires care and training to be used properly.

An important decision may depend upon the readings obtained.

Are they accurate? A case is discussed at length, defending the pros and cons of various procedures.

The decision to administer a drug to a patient is followed by a complex chain of events.

We must never allow any link in that chain to be broken.

In a hospital, everyone is busy.

Is he writing the order correctly? Should he check? Can routine become so commonplace that a mistake can creep in? The doctor does discover an error and corrects it.

Perhaps the wrong dose could have been fatal.

The nurse has an enormous job copying and recopying.

Each step provides the opportunity for mistakes.

There must be no letup in attendance to details.

Each procedure must be rechecked constantly.

How important is it to hurry? Does the patient's life hinge on the piece of paper she carries? The pharmacy has hundreds of drugs for a variety of purposes.

Accuracy is of obvious importance.

It is never acceptable to perform a task casually.

Errors will occur unless there is constant attention.

As the links in the chain are forged, it is clear that each must be sound.

One defective link will destroy the whole chain.

Memory is not to be trusted, not when the mission is so important.

With this medication, one person checks the other as an added precaution against error.

Preparing the medication is a long process, even boring at times.

This is a tempting situation, particularly when rushed and two people are required.

The precise dose is always of critical importance.

There are so many steps that there may be temptation to cut corners.

Each step is vital, contributing to the whole procedure.

I'm going to sack it for a while, okay? Was everything done correctly? Wait a minute, what order did I write? Oh no, I forgot to check.

It's not cc's, it's milligrams.

How can I be sure? Go back, pick up the prescription.

Don't, you took the wrong bag.

Did everything go wrong? No, no, that's the wrong ampule.

Don't spill it, the child needs all of it.

What happened? I just don't know, I'm sorry.

Oh my God, I better go check.

He's doing much better, don't worry.

Thank you for everything.

That's all right, okay.

But it's never happened to you, to your knowledge.

What will happen tomorrow? Hundreds of chains in the midst of tension, crisis, and overwork.

Will they each be intact?

Identifier

F.2014-06-0004

Date Of Production

1968

Abstract

A film geared towards medical professionals about the many opportunities for error within a hospital setting. The film, which was made at Chicago's Children's Memorial Hospital, specifically discusses the potential for error when prescribing medication to patients.

Run Time

0:11:47

Format

16mm

Extent

400 feet

Color

B&W

Sound

Optical

Reel/Tape Number

1/1

Has Been Digitized?

Yes

Language Of Materials

English

Element

Print

Genre

Medical (Non-fiction)

Form

Short

Subject

Medicine
Health

Related Collections

Jerome L. Schulman Collection

Related Places

North America ➜ United States ➜ Illinois ➜ Chicago

Main Credits

Schulman, Jerome L. (is producer)

Stewart, William H. (is director)

Additional Credits

Schulman, Jerome L. (is writer)

Blank, Charlotte (is contributor)

Stewart, William H. (is cinematographer)

Participants And Performers

Babcock, Frank (is narrator)

Barclay, Mary (is participant)

Bruette, Arlene (is participant)

Burg, Fred M.D. (is participant)

Cooper, John (is participant)

Fineberg, Dennis R., M.D. (is participant)

Lichterman, Edith (is participant)

Meyer, Marcia, R.N. (is participant)

Powless, Linda, R.N. (is participant)

Taub, Arnold, M.D. (is participant)

Zalutsky, Marlene (is participant)

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