Chapter 17 7. Do we still feel safe?

On November 7, 1997, "Shanxi Family News" reported that at 11 o'clock on October 27, 1996, Cai Xuehong, a 23-year-old employee of Anbu Power Plant in Anxian County, Chaozhou City, who was 39 weeks pregnant, was admitted to Anbu Overseas Chinese Hospital due to paroxysmal abdominal pain. Waiting to give birth, she was admitted to the obstetrics and gynecology department of the hospital.Previously, she had been to the obstetrics and gynecology department of the hospital, and had the last pre-labour examination, and it was confirmed that "the fetal position is normal, the baby is small, it is easy to give birth, the pregnant woman is in good spirits, the vital signs are normal, the fetal heart sounds are good, and the baby's head is exposed first." , no special changes in pregnant women".As a result, the puerpera was more at ease in the Huaqiao Hospital and waited happily for the birth of the little life. The whole family also looked forward to this happy moment with excitement...

The next day (28th) at about 9 o'clock in the morning, the mother's prenatal symptoms were the same as yesterday, and there was no development, and no fetus was born.At this time, Xiao Yongmin, an obstetrician and gynecologist, used a stimulant to "accelerate the labor process" for the parturient. At 10:45, the cervix of the parturient contracted rapidly, and the baby moved up. The parturient was in danger, endangering the lives of the parturient and the baby.The chief surgeon, Bi Lingzi, did not introduce the patient's dangerous situation to the mother's family members, and without the consent and signature of the mother's family members, performed caesarean section on the mother and carried the baby.Normally, as a general caesarean section, it only takes more than 20 minutes, but Cai Xuehong's caesarean section lasted for two hours, from 11:15 am to 14:00 pm. The baby has been out for more than an hour, and the mother is still in the hospital. Did not come out of the operating room.Afterwards, the hospital repeatedly emphasized that the operation went well.

The mother gave birth to a baby girl weighing 2.4 kg.After the operation, the mother was pushed back to the ward by her family members. She was extremely weak and her throat was very dry. Bi Lingzi prescribed some general Chinese medicine and antelope water for the patient.Within ten minutes, the patient developed chills and fever, followed by chills and high fever.The doctor gave her a simple antipyretic treatment.The patient's condition did not improve, but the doctors left one after another. In the early morning of the 29th, the mother began to have more serious symptoms of high fever, shaking all over.However, during the more than ten hours from early morning to 11:00 noon, no doctor came to make rounds.At around 9:00 in the morning, the patient's family members found that the mother's wound was bleeding a lot, seeping into the bed, so they looked for doctors everywhere to come for treatment. It was not until around 13:00 in the afternoon that a doctor was called. In this case, two stitches were sewed up for the mother on the hospital bed, but the mother still had a high fever.After repeated pleas from the patient's family, a nurse finally came to give her an antipyretic injection, and then put some ice to cool down the mother's side, and then disappeared.When the family members of pregnant women who were in a hurry went to the doctors and nurses' offices again and again to inquire, the extremely impatient doctors and nurses reprimanded them rudely.Before long, the woman's lower body was hemorrhaging profusely, bleeding from the incision, and bleeding from the mouth and nose. The situation was very serious and her life was at stake.However, the hospital delayed until around 1:15 pm before calling Chaozhou Health Hospital for help.During the nearly two hours from the hospital's call for help to the arrival of Dean Cai, the hospital was completely in a state of waiting for a "savior".When Dean Cai came in and saw that the woman was dying, he was so angry that his hands were shaking, and he immediately organized the manpower of the whole hospital to carry out the final rescue.However, because the hospital had delayed the emergency rescue for as long as three or four hours, Dean Cai was helpless.The rescue failed, and the mother died at 1:40 pm on the 29th.

After Cai Xuehong’s death, the Overseas Chinese Hospital issued the “Disease Death Certificate” to the deceased’s family on November 10, 1996. The conclusion was: “Cai Xuehong suffered from toxic dysentery after cesarean section with threatened uterine rupture, complicated by toxic shock, and functional failure. die." For this conclusion, Cai Xuehong's family expressed dissatisfaction.The family of the deceased insisted that this was caused by the doctor's serious dereliction of duty, misuse and early use of probiotics, causing adverse drug reactions, carelessness during the laparotomy, rupture of the incision, and supplementary needles on a hospital bed without any disinfection. Hospitals should be fully responsible for serious medical accidents that lead to maternal death due to infection after surgery and delays in the rescue process.The family members of the deceased raised doubts about a series of situations in the hospital's medical treatment and rescue process, such as the timing of the use of probiotics, the quality of the hospital's self-made glucose solution, and the blood oozing from the incision of the parturient due to lax suturing (or rupture), which made people suspicious. whether the operation was successful.A caesarean section that only took 20 minutes to complete took two hours, which made people suspicious; according to the relevant national regulations, the hospital should seal up the physical objects on site if there are adverse consequences caused by infusion, blood transfusion, injection, or medication. However, the Overseas Chinese Hospital did not keep it. According to the relevant regulations of the State Council, the autopsy should be carried out within 48 hours after death, but the hospital urged the family members of the deceased to do the funeral for the deceased as soon as possible. As a result, there will be disputes over medical accidents or medical accidents in the future, and it is impossible to provide scientific judgments. Basis; the hospital doctor took the initiative to ask for a total of 1,600 yuan in red envelopes from the mother’s family in the name of "lunch fee", whether it violated medical ethics; whether the dean on duty was absent from the hospital almost all day, whether he was negligent of his duty...

The family of the deceased has filed a lawsuit in court. "Henan Daily" Weekend Edition reported a medical accident in which an overdose of drugs caused deafness in a young child.Although in the end the court ruled that the hospital should pay 410,000 yuan, no amount of money can bring back a sound world for the child. On February 21, 1993, a boy was born in an ordinary worker's family in Dandong City. His parents named him "Wei Yi". When he was 5 months old, he already recognized people and made people laugh.He likes his mother hiding behind his back, clapping his hands and shouting "Wei Yi", when he hears that, he will turn back to find his mother and laugh non-stop. On July 22, 1993, Wei Yi had diarrhea, and his mother carried him to Dandong Hospital of Dandong Railway Branch, where he was born, for hospitalization. After being discharged from the hospital on July 24 and returning home, the whole family breathed a sigh of relief, but found that Wei Yi had no response to the game of "Mom calls Wei Yi".Diagnosed by a doctor at the Railway Hospital: The child has no other abnormalities, but seems to have a hearing problem.Since the hospital did not have examination equipment, the doctor suggested to go to the Second Hospital of Dandong City for a good examination.

For Wei Yi's family, August 12, 1993 was a black day.When the doctors of the Second Hospital stimulated Weiyi's ears with a short sound of 78 decibels, there was no response wave pattern on both sides, which means that Weiyi was already deaf.The medical staff of the Second Hospital sympathetically asked the child about the symptoms, and said that the child's deafness may be caused by excessive use of gentamicin. Wei Yi's mother, Tang Min, is a worker at the Plastic Parts Factory of the Dandong Railway Bureau, and his father, Zou Wensheng, is a worker at the Electric Power Bureau.In order to save the child, Tang Min gave up his job and sought medical treatment everywhere with Wei Yi in his arms.They withdrew all their savings, sold their valuable belongings, borrowed everything their relatives and friends could, and traveled all the way to Inner Mongolia, Dalian, Shenyang, Changchun and other places.

On November 6, 1995, Wei Yi was diagnosed with a 124 decibel non-response wave in both ears at Beijing Tongren Hospital.The honest parents looked up to the sky in despair and sighed. Is the child's life really like this? In a blink of an eye, Wei Yi is almost 3 years old, and he can't say anything except for the sound of "ahh".After two years of seeking medical treatment, I came to the conclusion that the child's hearing and pronunciation systems are normal. At this time, the child must be trained in speech, otherwise the child will not only be deaf for life, but also become dumb.

However, voice training is too expensive. In the past two years, they have almost lost their fortune. How can they have money for Wei Yi's voice training?The child's grandmother stepped forward at this time: "The railway hospital should take full responsibility for the child!" Weiyi's grandmother, Liu Yajun, is a worker at the Dandong No. 1 Cotton Weaving Factory. She devoted more love to her unfortunate grandson than she did to her own children.Not only did she use all her savings to treat Weiyi's illness, but she also accompanied Weiyi's mother and son on strange and distant medical journeys.

The first time I negotiated with the railway hospital, the hospital replied that I could go out for treatment and reimbursed the medical expenses.But in just one month, the railway hospital made an internal appraisal opinion: this case does not constitute a medical accident.Since then, Weiyi's medical expenses have not been reimbursed. Wei Yi received hearing and speech rehabilitation treatment at the Beijing Deaf Children's Rehabilitation Research Center for one month, and he can count from 1 to 10 stammeringly.For the first time, the whole family saw hope and smiled.However, the railway hospital's refusal to pay medical expenses puts Wei Yi in a desperate situation again.As a last resort, Wei Yi's family first appealed to the Health Department of the Dandong Railway Sub-bureau, and then petitioned the relevant departments of the Ministry of Railways level by level in order to seek justice.

In August 1997, I finally got the certificate from Dandong Medical Malpractice Appraisal Committee: Zou Weiyi binaural complete, sensorineural, neurological deafness; deafness caused by drug (gentamycin) poisoning; continued voice training; designated as Second-class medical technology accidents.However, when they went to the railway hospital with the testimonial, the hospital ignored them at all. In October 1997, the Railway Hospital entrusted Liaoning Provincial Medical Malpractice Appraisal Committee to reappraise. In January 1998, the Liaoning Medical Malpractice Appraisal Committee concluded that Zou Weiyi's medical dispute was still a second-class medical technical accident.

The appraisal conclusion made by Liaoning Provincial Medical Malpractice Appraisal Committee before the Spring Festival in 1998 once again encouraged Wei Yi's family.Since Wei Yi's accident, it has not been a good Spring Festival for four consecutive years.This year's Spring Festival, they thought, it's time to have a decent year.However, news came from New Year's Eve that the railway hospital still did not recognize the provincial medical malpractice appraisal.Liu Yajun, who was chopping dumpling stuffing, cut off his finger with a knife in grief and anger, and swore: "I've settled this lawsuit!" On July 15, 1998, "China Lawyer News" reported Wei Yi's misfortune under the title "They Want Justice for Their Children", and noted at the end of the article: "Wei Yi's family has no money to hire a lawyer. Those who are interested in providing legal aid to this unfortunate child should contact this newspaper." Gao Zhisheng, a lawyer from Xinghe Law Firm in Urumqi, Xinjiang, extended a helping hand to Wei Yi.The court opened on November 9, 1998. Lawyer Gao's representation brought many people present to tears. On February 11, 1999, the Dandong Intermediate Court made a civil judgment of first instance, and the Dandong Hospital of the Dandong Railway Branch compensated Zou Weiyi for medical expenses, food subsidies, nursing expenses, travel expenses, continuing treatment expenses, disability equipment expenses, and disability living allowances totaling 21 RMB 10,000, mental damage fee of RMB 200,000. 410,000 yuan is not a small amount for a family, but it is too cruel to exchange the child's life's health. Diagnosing the wrong disease, taking the wrong medicine, prescribing the wrong knife, transfusing the wrong blood... Medical accidents and medical mistakes have reached the point where we cannot prevent them, so many people go to the hospital, and they can't help praying silently in their hearts—but May medical malpractice not fall on my head! Although we are cautious, although we are trembling, we still cannot get out of the shadow of medical malpractice and medical errors.No one knows which day we, our family members, relatives and friends will step on the landmine of medical malpractice. ——Do we still have medical security? We have introduced many types of medical malpractice before, and some people may think that some cases are either special cases or special treatments.But there is probably nothing special about routine medical procedures such as enemas and intravenous infusions?But who would have thought that because some medical staff were sloppy in their work and did not carefully check the medicines or solutions they took, so that they took the wrong medicines or used them wrongly, it also made many irreparable big mistakes! "Forensic Medicine World" reported a series of such accidents in the first issue of 1995—— 1. Misuse of carbolic acid enema - the girl died instantly Carbolic acid, also known as phenol, is a commonly used disinfectant in operating rooms.It is a corrosive poison that can cause cell protein coagulation and cell necrosis; it also has a strong penetrating effect, can penetrate the coagulated mucosal epithelial cells into the blood, and act on the central nervous system.Because of its strong affinity with lipids, it is also a potent neurotoxin.At the beginning, there is a short-term excitatory effect, which quickly turns into paralysis, and often causes death due to paralysis of the respiratory center or heart paralysis. There is a 15-year-old girl named Hu who needs a cleansing enema because of abdominal surgery.When I came to the treatment room at 8 o'clock in the morning, Li, the nurse on duty, was chatting with another nurse about the popular clothes styles. When she saw that the patient wanted an enema, she took a bottle of liquid and gave her an enema.After infusion, the patient suddenly felt unbearable abdominal pain, sweating, tossing and turning, spitting foam at the mouth, rapid convulsions, coma, dyspnea, and irregular breathing.Another nurse hurriedly checked the medicine bottle used. It turned out that the 2% carbolic acid solution was mistaken for normal saline.A doctor was called in immediately for rescue, but it was too late. It took less than two hours from enema to breathing and cardiac arrest. An autopsy determined that Hu died of acute carbolic acid poisoning due to misuse of carbolic acid enema. 2. Misuse of formaldehyde enema - doctors and doctors will inevitably suffer Formaldehyde is an important disinfectant and tissue fixative, and is highly toxic to humans.Drug formalin contains 35%-40% formaldehyde.A commonly used solution is a diluted 4% solution.Formaldehyde is a severe corrosive drug. Even a highly diluted solution can coagulate tissue proteins and cause cell necrosis. A medical accident occurred in a certain area where a midwife was mistakenly given formaldehyde enema and died.A 27-year-old midwife was hospitalized and required an enema one morning for dry stools.A nurse mistakenly used 4% formaldehyde solution as 10% soapy water for an enema. As soon as about 50ml was instilled, the patient felt severe abdominal pain and nausea, which stopped the enema.After the nurse found that the enema had been misused, he immediately lavaged it twice with clean water, and gave detoxification measures such as glucose, charcoal powder, and egg white enema.In the afternoon of the same day, the abdominal pain was relieved, but the blood pressure continued to drop, and the heartbeat continued to increase. After 15 hours, the blood pressure could not be measured, and he fell into a coma.Afterwards, despite active rescue efforts, there was no hope of returning to life, and finally died after 20 hours of enema. The local forensic doctor conducted an autopsy and found that the main lesions were acute toxic, necrotizing, and hemorrhagic enteritis. The affected intestines included 180 cm of the ileum and the entire colon and rectum, and the cecum was the most severely damaged.It was identified as the death of acute formaldehyde poisoning caused by the misuse of formaldehyde solution enema. 3. Pollution of infusion solution of postoperative patients——burst of septic shock and death The most common medical malpractice in infusion is the infusion of contaminated liquid, which is mainly because the pollution in the pharmaceutical process is related to lax inspection.A gastric cancer patient felt fine after subtotal gastrectomy and gastrojejunostomy.On the third day after the operation, rehydration was given. After about 1.5 hours, the patient suddenly felt chills, followed by high fever, irritability, convulsions, and a drop in blood pressure.It was suspected that there was something wrong with the input glucose solution, and the glucose solution and blood were taken for bacterial culture, and Escherichia coli grew there.Diagnosed as infection toxic shock, renal failure, shock lung.The rescue failed, and the patient died 92 hours after the onset of the disease. The forensic autopsy found serious lesions such as renal tubular necrosis, diffuse centrilobular necrosis in the liver, acute myocardial inflammation, and infectious splenomegaly.Combined with his clinical experience and the results of bacterial culture, the patient died of septic shock caused by bacterial contamination of the infused glucose solution. 4. The infusion was actually kerosene—the patient with bacillary dysentery almost died This happened in a rural hospital.There was a bottle of kerosene in the disposal room of this hospital, which was filled with infusion bottles and placed on top of the medicine cabinet, which laid the root of the accident.One afternoon, patient Li was suffering from bacillary dysentery and needed to be infused with 5% glucose solution. When he came to the treatment room, the doctor on duty, Wang, had just returned from playing mahjong.Wang was complacent because he was so successful, and the shadow of mahjong still swayed in front of his eyes from time to time. He took off the bottle of kerosene by mistake and put it on the infusion.In less than half an hour, the patient felt the smell of kerosene and felt euphoric like drinking alcohol. He developed a cough, burning pain in the chest, shortness of breath, irritability, and then fell into a coma with delirium from time to time.Only then did Wang rush to rescue him.It wasn't until the next morning that Li gradually recovered, but he was still listless, with elevated body temperature, frequent pulse, shortness of breath and shallow breathing.Signs of pulmonary involvement gradually appear later: pulmonary hemorrhage, edema, inflammation, and tissue necrosis.Empyema and pneumothorax occurred due to secondary infection. After surgical drainage and other symptomatic treatment, he was hospitalized for nearly two months and gradually recovered. 5. Air embolism scares people to death Patient Chen was admitted to hospital due to acute gastroenteritis.The nurse supplemented the fluid according to the doctor's advice and gave 5% glucose solution intravenously.When the liquid medicine was about 120ml left, the impatient nurse used a 50ml syringe to push air into the infusion bottle five times in order to speed up the infusion, and the volume reached 200 to 250ml. When there were 2 to 3 ml left in the tube, the needle was not pulled out in time, and while the tape was being torn off to fix the needle hole and the needle was pulled out, the sound of air entering the venous cavity was heard.Immediately the patient developed shock such as headache, vertigo, chest tightness, nausea, vomiting, pale complexion, dyspnea, cyanosis of the lips, drop in blood pressure, muffled heart sounds, and rapid pulse rate.Immediate rescue was organized, and the patient survived. Medical accidents occur frequently, which is hard to prevent.People can't help asking: who made the medical malpractice?Of course, there are quite complicated reasons for the occurrence of medical accidents, but one of the most critical and unforgivable reasons is the dereliction of duty of medical personnel.Looking through the medical malpractice files soaked in blood and tears, it is not difficult for us to find that it is the dereliction of duty of some people and the reluctance of some people to save lives that caused this medical malpractice that killed lives and damaged health. In recent years, obstetric accidents have increased significantly, seriously threatening the lives of pregnant women and babies.The reasons are, first of all, prevarication and rejection of critically ill patients and pregnant women, leading to ectopic pregnancy shock, dystocia, hemorrhage, intrauterine asphyxia, and delivery outside the delivery room, resulting in adverse consequences.The second is the violation of the operating procedures, non-emergency operations and deliveries outside the delivery room in the operating room; the use of oxytocin, ergot, fetal head suction, and forceps to help end the delivery if the uterus is not fully dilated; postpartum observation is not performed, and the puerpera is transferred prematurely. Moving to the ward causes serious damage to the soft birth canal, postpartum hemorrhage, infection, birth trauma to the baby, and other adverse outcomes.In addition, inappropriate rapid blood and fluid transfusions in non-emergency situations may cause cardiopulmonary failure, or failure to observe closely after using uterotonics may lead to uterine rupture, resulting in death and disability of mothers and infants. Many obstetric accidents are closely related to the negligence of medical staff.A woman had a high fever after giving birth, but the attending physician went out for a day without any treatment. The temperature continued to rise the next day, but the doctor still did not pay attention to it, and only asked the mother's family members to use alcohol to physically cool down.At 8 o'clock that night, the mother still had a high fever, and the family members went to the doctor, but he refused to see her.At 9:00 p.m., the nurse reported that the mother’s body temperature was still rising, and the doctor said, “Give me some penicillin.” At 11:00 p.m., the family went to the doctor again, and he sent the nurse to ask. , namely pull out the needle and observe.At 11:30 p.m., he came to see the parturient at the repeated request of the family members. When he arrived at the ward, he first reprimanded the family members for pulling out the needle. I'm stuck." After saying that, he went back to sleep.At 3:30 the next morning, the mother was extremely irritable, bloated, and her blood pressure dropped. The family members called the superintendent on duty and immediately rescued her. Died of encephalomalacia.This is a typical puerperal infection, but because the treating doctor left his post without taking any measures, he treated the postpartum infection as a cold, and called himself up for treatment because he was "afraid of having a reaction at night", so he interrupted the intravenous injection of antibiotics and delayed the treatment. Treatment has lost the favorable opportunity to control the development of the disease. Medical accidents related to anesthesia, including overdose of anesthetics, drug allergies, operating errors or violations of operating procedures, misuse of local anesthetics for spraying as intravenous injections, etc. Anesthesia is a complex technique. Anesthesia drugs are mostly highly poisonous drugs, which are more toxic than ordinary drugs, and the dosage is large, so the risk is also great.A 27-year-old patient underwent radical mastoidectomy on the right ear under general anesthesia, and the operation started smoothly. At the beginning of the operation, the patient was agitated due to the lightening of the anesthesia. From deep and fast at the beginning to slow and weak, the blood pressure could not be heard clearly, and then the heartbeat and breathing stopped suddenly. The doctor realized that it might be an overdose of ether and rescued him. Cerebral edema was severe, leaving the patient with a sequela of cerebral hypoxia - dementia, unable to take care of himself. Blood transfusion accidents are mainly transfusion of abnormal blood.Mistakes in bottling after blood collection, delivery of wrong blood, and wearing of crowns during blood transfusions can all cause blood type errors in blood transfusions.Transfusion of incompatible blood, if not found in time, will produce anaphylactic shock or severe hemolysis reaction and lead to acute renal failure and even death.There was a female patient surnamed Xu who needed a hysterectomy for uterine fibroids.A hospital doctor named Xuan led the trainee doctor Wu to take charge of the anesthesia for the operation.During the operation, the patient's blood pressure suddenly dropped, which was caused by excessive blood loss during the operation.Xuan then asked Wu to go to the blood bank with the patient's medical record card and blood slip.After receiving the blood collection receipt held by Wu, the examiner Huang did not check it according to the regulations, and heard Wu's gynecology as orthopedics. to Wu.After Wu returned to the operating room, he handed over the two bags of blood together with Xia's cross-matching test sheet and Xu's medical record to Xuan for checking, but Xuan mistakenly believed that they had been checked by the blood bank and the blood receiving personnel, and there was no mistake, so they did not carry out the check. According to relevant regulations, type B blood was transfused into Xu's body.Xu's blood type is O type. When about 80 ml of blood was transfused, Xu immediately experienced abnormal symptoms such as blood pressure drop and chills.Xuan also mistook it for a general blood transfusion reaction and injected Xu with anti-allergic drugs.Later, Xu's blood pressure dropped, and Xuan believed that excessive blood loss caused hypovolemia, and then gave Xu another 200 ml of type B whole plasma.When Xuan sent Wu Zai to the blood bank to get blood, he found out that the wrong blood had been transfused, but it was too late. As a result, the patient's blood pressure dropped sharply and he developed shock symptoms. The hospital leaders immediately organized rescue, but the rescue failed. die. To prevent accidents, we must adhere to the checking system before blood transfusion, and check the blood type, name, and bank number. When a blood transfusion reaction occurs, the blood transfusion should be stopped immediately, and the cause of the reaction should be checked while actively dealing with it. Most of the medical accidents related to nursing work are due to failure to follow rules and violation of operating procedures.In hospitals, nursing staff account for half of the total number of health technicians, and nearly 3/4 of the departments they directly participate in management and work.From outpatient visits, hospitalization, until recovery and discharge, every job requires the close cooperation of doctors and nurses.Nurses have the most direct contact with patients in the ward, and they are most familiar with the condition, so their work is directly related to the quality of medical care.According to the analysis, 95% of the 100 cases of nursing errors occurred in the ward, among which the wrong medicine (including intravenous injection, intramuscular injection and oral administration) accounted for 50%, violation of operating procedures accounted for 12%, nursing work accidents in the baby room accounted for 12%, and enemas accounted for 50%. Operations accounted for 8%, blood transfusion accidents accounted for 6%, unsound systems or other factors accounted for 10%.Specifically in: One is the error in the execution of the doctor's order.Some nurses change the route of medication prescribed by the doctor: if the doctor ordered intramuscular injection, it was changed to intravenous injection; the doctor ordered oral medicine to be changed to intravenous drip;According to "People's Daily", an old nurse in the emergency room of a large hospital in Shanghai was not serious about carrying out the doctor's orders for a sick child. The doctor prescribed soap enema, but the nurse blindly put the "creol" by the sink. "Soap" is placed in the anal injector and the enema is performed immediately.After feeding, the sick child immediately convulsed and then fell into a coma, and died after rescue.The family members sued the court and the nurse was brought to justice.There are also doctors who violate oral medical orders.Oral doctor's orders are limited to emergency rescue and when on the operating table, but some doctors give oral doctor's orders in non-emergency situations, instead of seeing patients, they give oral doctor's orders on the phone, lying under the quilt or even playing chess in the duty room. Nursing jobs create chaos. The second is that the implementation of the checking system is not serious.What is more common is that the medication is not checked strictly, and the name of the medicine signed on the bottle is not checked, and the medicine is taken at hand, or the medicine is given without checking the name of the medicine only by looking at the packaging.For example, a parturient undergoes a cesarean section under local anesthesia, and feels chest tightness and discomfort two hours after the operation. The doctor ordered intravenous injection of 50% glucose, but the nurse did not check the name of the drug, so she sucked two medicines into the needle and gave the parturient an intravenous injection.When the injection reached 10ml, the parturient experienced symptoms such as agitation and twitching of the limbs. At this time, the nurse did not stop the injection to find out the reason, but asked the family members to hold the parturient until the liquid was pushed out, and the parturient died instantly.After examination, the nurse mistakenly took 2% lidocaine as glucose injection and died of poisoning. Misuse of drugs, drug allergies, and drug poisoning are the most common medical malpractice and medical errors.Although the medical departments have stipulated a strict drug inspection system, in actual operation, many people do not take it seriously. "Three checks and seven pairs" go through the motions and engage in formalities. Once an accident occurs, it will be too late to regret it.Misuse of drugs, the most common is the misplacement of drugs, self-confidence will not be wrong without checking, so that it is misused.There was a 9-month-old boy who was suffering from intussusception and underwent emergency surgery. Before the operation, 5% glucose saline was intravenously dripped and 20ml of 5% baking soda was injected intravenously. The nurse on duty stored the 5% baking soda injection Two tubes of potassium chloride were taken out from the medicine cabinet and injected intravenously without checking. When 10 ml was injected, the sick child suddenly convulsed, foamed at the mouth, had difficulty breathing, and died after rescue failed.Some nurses do not carefully check the dosage of drugs.For example, a nurse took a bottle of aminophylline with a content of 500 mg as 50 mg, and took 2/3 of it to give intramuscular injection to the sick child, and died due to the dose exceeding 10 times. Third, drug management is chaotic.Highly toxic drugs are stored mixed with general drugs; internal medicines and external medicines are stored in the same place; medicines are taken from fixed locations based on impressions and experience; suspicious medicines are not investigated, such as medicines without bottle labels, which are rashly used in clinical practice based on experience, resulting in the death of patients .The pharmacy of a certain hospital was poorly managed, and the arsenic lost its label. A pharmacist in charge of the management judged that it was Glauber's salt and sent it to the pharmacy without inspection. As a result, several people were poisoned, and three of them died. The fourth is not to seriously implement the technical operating procedures.The essence of nursing technical operation routine is to standardize, standardize and program the nursing technical operation. The purpose is to strictly control the quality of nursing, prevent technical operation errors, and prevent accidents.But in reality, many people do not seriously implement the technical operation procedures, which lead to accidents, including spillage of intravenous drug solution, gastric perforation caused by improper gastric lavage, burns during treatment, broken needles, etc.On the sixth day after a baby boy was born, when two nurses on duty were changing his diaper, they found that there was stool stained on his body and cotton clothes, so they brought a hot water basin to wash the baby's buttocks.She didn’t test the water temperature before washing, but directly put the baby’s lower body into the hot water basin. A nurse found that the baby’s skin was flushed and the skin on the feet was peeling. That!" Without reporting to the doctor, he took the baby to the mother's place to nurse, and left the ward without permission to take a bath.When one of the nurses returned to the nursery after taking a shower, it was already 6:30 pm, and then she went to wash clothes and cook.When she went to the mother to pick up the baby again, the mother reminded her that "the baby is not in good condition". She thought it was because the hugging skirt was too tight. Doctors deal with.Check the baby's buttocks and lower limbs for 30% to 40% burn area, of which 20% are superficial second degree, which is diagnosed as severe burn.Emergency rescue was organized immediately, but it was too late. The baby developed secondary infection and sepsis, and died on the fifth day after being scalded. Fifth, they are not strict with their duties, do not patrol the wards carefully, do not pay attention to the main complaints of patients and their families, so that they miss the details of the patient's life-threatening illness, or neglect their duties, do not stick to their posts, and do not concentrate on work etc., leading to medical malpractice.A nurse on duty in a baby room nursed two newborns four days after birth. One of the boys cried continuously after feeding, and continued to cry after feeding. She thought the baby was crying, so she turned him over and placed him in a prone position.After feeding other children, go to other tasks.After 45 minutes, she suddenly remembered that the two babies had been turned over, and immediately went to the nursery. When she turned the two babies over, she found that both were pale and had stopped breathing. From the above cases, we can see that every aspect of the work of medical staff is closely related to patients.Any of their negligence and carelessness will cause irreparable losses to the patients.As a special profession related to the life and death of patients, we have reason to require medical staff to treat patients enthusiastically and carry out medical diagnosis and treatment work seriously and responsibly from the perspective of humanitarianism.Only in this way can the hospital truly be the safest shelter for human beings, and the medical staff truly be the most respected life protectors of human beings!