better? How could they not have noticed?’ You think you can solve your human error problem
by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or
procedure. They are all expressions of the ‘Bad Apple Theory’ where you believe your system is
basically safe if it were not for those few unreliable people in it. This old view of human error is
increasingly outdated and will lead you nowhere.’ – Sidney Dekker.
Ketika dihadapkan dengan masalah kesalahan manusia Anda mungkin tergoda untuk
bertanya 'Mengapa mereka tidak hati-hati dengan lebih baik? Bagaimana mungkin
mereka tidak menyadarinya? 'Anda pikir Anda bisa mengatasi masalah kesalahan
manusia Anda dengan mengatakan kepada orang-orang agar lebih berhati-hati, dengan
menegur para penjahat, dengan mengeluarkan peraturan atau prosedur baru. Mereka
semua merupakan ungkapan 'Bad Apple Theory' di mana Anda yakin sistem Anda pada
dasarnya aman jika bukan karena beberapa orang yang tidak dapat dipercaya di
dalamnya. Pandangan lama tentang kesalahan manusia ini semakin usang dan tidak akan
membawa Anda ke mana-mana. '- Sidney Dekker.
Current health care safety lends upon ‘Bad Apple Theory’ relying on alerts, education and
policies in response to adverse events.
In 2010 Grace Wang was paralysed when indistinct chlorhexidine (solution centre of image) was
mistaken for saline (left of image) and injected into her epidural. Distinct chlorhexidine (right of
image) and non-pourable versions are used without problem and at no extra cost in many
institutions.
Perawatan kesehatan saat ini mengutamakan 'Bad Apple Theory' yang mengandalkan
peringatan, pendidikan dan kebijakan sebagai tanggapan atas kejadian buruk.
Pada tahun 2010 Grace Wang lumpuh saat klorheksidin tidak jelas (pusat solusi gambar)
disalahartikan sebagai saline (kiri gambar) dan disuntikkan ke epiduralnya. Klorheksidin
yang berbeda (right of image) dan versi non-pourable digunakan tanpa masalah dan tanpa
biaya tambahan di banyak institusi.
Grace is one of hundreds of patients who’ve suffered because this unnecessary hazard exists in
our hospitals (see here).
The NSW Health response to the Grace Wang incident was an alert outlining essential procedure
when using antiseptic solutions:
Grace adalah satu dari ratusan pasien yang telah menderita karena bahaya yang tidak
perlu ini ada di rumah sakit kami (lihat di sini).
Respon Kesehatan NSW terhadap insiden Grace Wang adalah peringatan yang
menguraikan prosedur penting saat menggunakan solusi antiseptik:
However indistinct preparations of chlorhexidine still exist in many hospitals leaving patients at
unnecessary risk. Attempts to have it banned through current health care frameworks have been
unsuccessful.
Melarang Tuntutan yang tidak jelas Chlorhexidine
Pada tahun 2010 sebuah kejadian tragis dimana klorheksidin dikalsinasi karena garam
meninggalkan Grace Wang lumpuh (lihat di sini). Investigasi formal atas kejadian
tersebut membuat rekomendasi ini:
Namun persiapan klorheksidin yang tidak jelas masih ada di banyak rumah sakit sehingga
pasien tidak perlu berisiko. Upaya untuk melarangnya melalui kerangka kerja perawatan
kesehatan saat ini tidak berhasil
Numerous similar cases of inadvertent chlorhexidine injection have occurred (see here) leading
to amputations, paralysis and deaths. All have occurred in the presence of pourable, almost
colourless versions of chlorhexidine.
We need your support – please click here and sign the petition to ban indistinct pourable
chlorhexidine – this goes straight to regulating authorities and manufacturers.
Sejumlah kasus injeksi klorheksidin yang tidak disengaja telah terjadi (lihat di sini)
menyebabkan amputasi, kelumpuhan dan kematian. Semua telah terjadi dengan adanya
versi chlorhexidine yang lumayan dan hampir tidak berwarna.
Kami membutuhkan dukungan Anda - silakan klik di sini dan tandatangani petisi untuk
melarang klorinheksidin yang tidak jelas - ini berlaku langsung untuk mengatur otoritas
dan produsen.
There’s no need for these indistinct solutions and safer versions are already in use in many
hospitals without problem and at no extra cost.
Watch ‘Gina’s Story’ to see how arterial injection resulted in leg amputation at the waist.
Read ‘Mary McLinton’s Story’ – she had chlorhexidine injected into the blood supply to her
brain. She died two weeks later in agony, at one point begging a nurse to kill her.
“No one took action to change the process before this tragedy occurred.”
We’re trying but need your help. Please sign the petition here.
Why haven’t the numerous chlorhexidine injection cases been identified before?
Why don’t we just stop ordering pourable pink chlorhexidine into hospitals?
What were the recommendations in response to the St George Hospital epidural tragedy?
Unfortunately the only thing stopping us banning indistinct pourable chlorhexidine is us and the
deficient health care safety systems we’ve created.
Let’s change this – please sign the petition to ban indistinct pourable chlorhexidine.
Tidak perlu solusi yang tidak pasti dan versi yang lebih aman ini sudah digunakan di
banyak rumah sakit tanpa masalah dan tanpa biaya tambahan.
Perhatikan 'Kisah Gina' untuk melihat bagaimana suntikan arteri menghasilkan amputasi
kaki di bagian pinggang.
Baca 'Kisah Mary McLinton' - dia menderita klorheksidin yang disuntikkan ke suplai
darah ke otaknya. Dia meninggal dua minggu kemudian karena kesakitan, pada suatu
saat mengemis seorang perawat untuk membunuhnya.
"Tidak ada yang mengambil tindakan untuk mengubah proses sebelum tragedi ini
terjadi."
Kami mencoba tapi butuh bantuanmu Silahkan masuk petisi disini
Pertanyaan yang Sering Diajukan:
Berapa banyak kasus yang telah terjadi?
Mengapa tidak banyak kasus injeksi klorheksidin telah diidentifikasi sebelumnya?
Apa pendapat staf garis depan?
Mengapa kita tidak berhenti memesan chlorhexidine merah muda ke dalam rumah sakit?
Apakah produsen telah menyadari masalah ini?
Mengapa tidak semua orang memberi label pada gallipot?
Mengapa tidak hanya menggunakan yodium?
Bagaimana dengan penggunaan aplikator chlorhexidine?
Persiapan chlorhexidine mana yang harus kita gunakan?
Mengapa staf tidak bisa 'lebih berhati-hati'?
Apa rekomendasi dalam menanggapi tragedi epidural St George Hospital?
Mengapa belum mengatur pengarang sudah melarangnya?
Sayangnya satu-satunya hal yang menghentikan kita melarang klorinheksidin yang tidak
jelas adalah kita dan sistem keselamatan perawatan kesehatan yang kurang yang telah
kita buat.
Mari kita ubah ini - tolong tanda tangani petisi untuk melarang klorheksidin yang tidak
jelas.
Alerts such as these are part of the top down safety response which is used in healthcare. Many
years ago an alert like this may have had some effect, however healthcare is now too complex
for interventions like this to have sufficient impact.
Human Factors Engineering teaches us this alert has not created a safe system leaving patients at
unnecessary risk.
The Root Cause Analysis performed after the St George event (see here) recommended
antiseptic solutions be distinctly coloured – this recommendation has not been instituted.
Given that banning indistinct chlorhexidine appears a simple safety solution, why hasn’t this
already been done?
Perhaps legal ramifications and the repercussion from manufacturers makes regulating bodies
(TGA, FDA, MHRA etc) hesitant to act.
How do we instill courage in governing bodies to provide us with safer work environments?
When indistinct chlorhexidine is banned know that this has happened (please sign the petition
here). We will have gifted ourselves with a framework to start optimising patient safety.
Lansiran seperti ini merupakan bagian dari respon keamanan atas yang digunakan dalam
perawatan kesehatan. Bertahun-tahun yang lalu sebuah peringatan seperti ini mungkin
memiliki beberapa efek, namun perawatan kesehatan sekarang terlalu rumit karena
intervensi seperti ini memiliki dampak yang cukup.
Teknik Human Factor mengajarkan kita bahwa peringatan ini belum menciptakan sistem
yang aman sehingga pasien tidak perlu mengambil risiko.
Analisis Penyebab Akar yang dilakukan setelah acara St George (lihat di sini)
merekomendasikan solusi antiseptik diwarnai dengan jelas - rekomendasi ini belum
dilembagakan.
Tidak ada laporan pemberian keliru saat klorheksidin yang berbeda atau tidak dapat
dituang digunakan. Staf garis depan tidak ingin klorheksidin tumpul yang tidak jelas di
rumah sakit. Lebih dari 350 orang sekarang telah menandatangani petisi yang meminta
agar dilarang. Kami memahami kompleksitas lingkungan kerja kami, slip dan
penyimpangan terjadi dan 'keliru adalah manusia'. Kami takut untuk pasien kami dan
takut untuk diri kita menjadi 'korban kedua' berikutnya.
Mengingat bahwa pelarutan klorheksidin tidak jelas muncul solusi keamanan sederhana,
mengapa hal ini belum dilakukan?
Mungkin konsekuensi hukum dan dampak dari produsen membuat badan pengatur
(TGA, FDA, MHRA dll) ragu untuk bertindak.
Bagaimana kita menanamkan keberanian dalam mengatur badan untuk memberi kita
lingkungan kerja yang lebih aman?
Bila klorheksidin yang tidak jelas dilarang mengetahui bahwa ini telah terjadi (mohon
tanda tangani petisi di sini). Kami akan memberi diri kami kerangka kerja untuk mulai
mengoptimalkan keselamatan pasien.
There is a moment soon after major financial crises erupt when it dawns on public officials what
went wrong. They draw up ambitious plans for meaningful change but these plans are soon
rolled away as the wider society adopts what I call "The Bad Apple Theory of Financial Crises."
According to this theory, crooked bankers using evil products cause financial crises. We just
need to banish them. Politicians are keen proponents of the Bad Apple Theory. It shifts blame
from their regulatory policies. They can show the electorate that they are swinging into action to
ban stuff. Bankers like it too. They can sacrifice a few arrivistes and carry on. The media revel
in the Bad Apple Theory. It lets them brush over the advertising revenues they lapped up before
the crisis and the fawning copy it bought, and focus instead on bringing down those they had
previously built up.
The Bad Apple Theory dominated the thinking behind the tepid initiatives at the end of the
Dotcom debacle of 1999—2001, the Asian financial crisis of 1997—98, and the Latin American
debt crisis of the 1980s. Not since the Great Crash of 1929 did a financial crisis lead to a
complete redrawing of the financial system. Crises are more structural than a few bad apples.
The dominance of the Bad Apple Theory in the popular discourse condemns us to repeat the
cycle of boom-bust.
The balkanization of news providers by cable and the Internet have meant that the most common
frame of reference today comes from movies. Oliver Stone's Money Never Sleeps (2010) and J.
C. Chandon'sMargin Call are two of the best examples of movies about the crisis that adhere to
the classical Bad Apple Theory. The version of the theory favored by politicians and bankers is
generally too one-dimensional to sustain two hours of entertainment, and so the Hollywood
version adds sinister conspiracy to the story of omnipotent banks defrauding ordinary people.
Andrew Ross Sorkin's Too Big to Fail in 2011 is a fine example. Even in films, it is the early
observations about the crisis that are more radical. Michael Moore's Capitalism a Love
Story (2009) and Charles Ferguson's Inside Job (2010) convey the wider corruption of the
financial industry. Michael Lewis wrote The Big Short around the same time, but Adam
Mackay's film version has only been released recently. It captures the different characters at
banks and hedge funds better than any other movie and has the best explanation of mortgage-
backed securities. Having done the hard work, it is let down by an end which leads us to the
usual suspect: criminal fraud by banks.
If before the crisis all those who committed illegal behavior had somehow been locked up and
the banks had been broken up, the crisis and its untold human suffering would still have been as
big. Illegal things happened, but they did so at the margins. Better enforcement of regulations
would not have changed anything because regulatory incentives were the chief cause of it. The
Big Short rightly hints that aspirations for a job at the banks played a role in the obsequiousness
of regulators. But the main avenue of regulatory capture was the prevailing societal view from
the 1980s onwards that markets were good and governments were bad. Politicians got elected to
cut red tape, and banks rolled out Nobel Prize—winning economists to explain why we should
leave regulation to the markets.
It was regulators themselves who, in the name of safety, created the merry-go-round where
banks packaged their mortgages together into a market security that they sold to other banks and
then used the proceeds to buy the packaged mortgages of other banks. Those that did were
allowed to hold considerably less regulatory capital and, therefore, make more profit than those
that did not. This rule came into force in 1988 when the market ideology was still ascending,
and it was from that point that securitized mortgages took off.
Ten years later, regulators brought credit ratings into the assessment of the amount of capital
(cash not debt) required to fund securitized mortgages and imposed disclosure on the makeup of
their ratings. This information allowed banks to build packages of debt to a rating, aggressively
seeking out the lowest-rated debt that once spread would preserve the rating of a security. The
process destroyed the statistical independence that lay behind the ratings. Diversified packages
of the small amount of subprime debt were low risk originally, but over-exploitation of this
statistical observation turned them into risky assets. There was some illegality, much greed, even
more foolishness, but mainly the close following of flawed regulation.
Financial booms occur when markets become convinced that some innovation has made the
world a safer place. At the top of the boom, just when banks and others should be pulling back,
the market assessment is that risks are small and so banks and others can safely double up on
debt. Markets serve many useful purposes, but 800 years of financial folly has taught us that a
collective underestimation of risks in the good times and later overestimation causes booms and
busts. As long as regulators and their political masters believe that the best response to market
failure is to rely more on markets, then booms and busts will keep on coming however many
bankers you lock up.