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Organizations and Human Error

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Crisis Management in Acute Care Settings

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Abstract

A 32-year-old worker fell from the top of a 4-m scaffold and hit the ground on his right side. Emergency medical services (EMS) evaluated the patient, who was found to be alert and hemodynamically stable. He was transported to the Emergency Department of a nearby hospital for further evaluation. There, the emergency physician was extremely busy taking care of six emergencies while other patients were also waiting to be evaluated. On arrival, the blood pressure and heart rate were within normal limits and the lungs were clear to auscultation. The patient’s chief complaint was localized pain on the right side of his chest that worsened with deep breathing and moving. The patient had a chest X-ray (CXR) done in the Radiology Department, but the radiology technician who had the habit of identifying patients based only on their last name erroneously distributed the wrong films. The patient received a set of normal CXR films that belonged to a different patient with the same last name.

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Editor information

Editors and Affiliations

  1. Department of Anesthesiology, University of Erlangen, Krankenhausstrasse 12, 91054, Erlangen, Germany

    Michael St. Pierre

  2. Hohenheimerstrasse 104, 71686, Remseck, Germany

    Gesine Hofinger

  3. Woehlerstrasse 12, 10115, Berlin, Germany

    Cornelius Buerschaper

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© 2008 Springer-Verlag Berlin Heidelberg

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(2008). Organizations and Human Error. In: St. Pierre, M., Hofinger, G., Buerschaper, C. (eds) Crisis Management in Acute Care Settings. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-540-71062-2_14

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  • DOI: https://doi.org/10.1007/978-3-540-71062-2_14

  • Publisher Name: Springer, Berlin, Heidelberg

  • Print ISBN: 978-3-540-71061-5

  • Online ISBN: 978-3-540-71062-2

  • eBook Packages: MedicineMedicine (R0)

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