Examples of the importance of recording paper in the medical field

Time : 2022-12-22

As a doctor, what do you do if your defibrillator doesn't work during an emergency? Similar problems, if you don't understand the reason, often cause serious consequences.

A patient died in the ICU of a certain hospital.

The family members complained that the monitor alarmed for half an hour, but no doctor or nurse came to deal with it. The hospital said it had been rescued in time. However, since the patient's medical data in the monitor was not recorded, the memory data was automatically deleted after 24 hours, and the data was not preserved, so it was impossible to prove the hospital's statement. This situation exists in many hospitals. Emergency monitors do not have recording devices, some are for cost saving, and some have recording devices without recording paper.  The preservation of patient information is the key to proof, and the above case shows that there are loopholes in hospital management.

In the medical records of a deceased patient, the time printed by the device was different from the actual time, and the actual time of death was 35 minutes longer than the time printed by the monitor, which resulted in a doctor-patient dispute. The reason is that the monitor has not been calibrated regularly, which is later than the actual time. The family members of the patient believed that the doctor was not able to shirk the responsibility because the doctor only discovered the patient 35 minutes after the death.

There is no benefit in defibrillating a heart that has stopped beating.

However, in a small number of patients, there is a coarse VF waveform, and the corresponding lead has only a very fine fibrillation. This is called latent VF. A straight line, similar to cardiac arrest. Checking the rhythm in both leads can help identify this phenomenon. If there is no power supply, no leads connected, wrong parameter settings or incorrect lead selection, etc., the ECG will also appear in a straight line, making the doctor mistakenly think that the patient's heart is in cardiac arrest. To make matters worse, there are more cases of ventricular fibrillation due to technical reasons than true latent ventricular fibrillation.

The purpose is that clinicians are more interested in the use and usage skills of medical equipment, but seldom pay attention to other relevant data of medical equipment in the second team, and it is precisely these problems that are one of the keys to reducing medical errors.