An intravenous (IV) infusion called a vasopressor is a major, underappreciated hazard when given to someone in the throes of poor cardiac output. It is a mistake recognized by anyone with even a basic understanding of hemodynamics, yet it has happened in every cardiac surgical operating room (OR) and intensive care unit (ICU) where I […]
Month: July 2023
THE PROBLEM WITH NONPUNITIVE SAFETY CULTURE
It is widely accepted nowadays that punishment for making errors is the greatest impediment to safety in health care. This was not always the prevailing view. The first effort to improve the safety of surgery can be traced back 3,800 years to the Babylonian Code of Hammurabi: “If a surgeon performs a major operation and […]
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