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That does not sound like defense of current system at all. It sounds like lack of process and system, relying on individual memory and recall instead.

In particular, both OB and PT on wrong limb are not just handover errors. First I am bit surprised that babies and miscarriages mix - they don't in here (so you know which it is based on room, but I think cause of split is something else). PT on wrong limb is error of not checking what you are supposed to do before administering - but also sounds like error people are more likely to do under time pressure or when tired and falling into routine.

All in all, after major procedure you are in hospital for days and they have to move you between doctors and nurses many times.



I hope it doesn’t sound like a defense. IMO this is a broken system that needlessly kills people as a matter of bureaucratic inertia.

Surgeries performed by the Ob/Gyns are housed on a specific floor. The situation was that there wasn’t a transition as the shifts changed due to understaffing, and the person doing rounds didn’t bother to read the chart.

In my surgical recovery state, the reasoning was poor situational awareness and burden on the nurses. Data was located in 4 different EMRs and they missed it.

Half my family is engaged in various medical professions. Every one of them is dissatisfied with how these systems work.




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