atans1

Iran’s “Ownself shoot ownself” reminds me of SGH tragedy

In Public Administration on 30/01/2020 at 10:42 am

When I read sometime back that Iran’s president Rouhani saying that the shooting down of an airliner should not be blamed on one individual, saying “It’s not only the person who pulled the trigger, but also others who are responsible”, it reminded of

What really went wrong at SGH?

And why the reluctance to do more than issue letters of warning?

a piece I wrote in 2016 about an incident at SGH where 25 people were infected and seven deaths were possibly caused by the cock-up

The piece went on:

A regular reader and commenter of this blog who seems to have been  a medical doctor and administrator has an explanation.

Note he had already raised the issue of the use of shared vials here before the internal report came out. He goes further below presumably having read the internal report.

This WAS a systems failure whereby the major gap was allowing same vial of insulin for multiple patients i.e. shared vials, although supposedly using fresh, sterile needles & syringes. By using shared vials, this created a single point of failure if any of the 1,001 aspects of infection control was not strictly adhered to. E.g. lack of hand disinfection — between patients, before drug preparation, before administering insulin, after administering insulin; not disinfecting the rubber bung of the shared vial adequately before use; not using new sterile needles/syringes; using new sterile needles/syringes but leaving them exposed for too long or mishandling them thus rendering them no longer sterile; etc etc. The possibilities are endless.

And then the pathogen being introduced into the shared vial and subsequently being re-transmitted, even though subsequent usage all followed 100% infection control — the bug is already in the insulin/vial, no matter how solid & how sterile you prepare the subsequent insulin administrations for other patients, you’re simply injecting them with already contaminated insulin.

Who’s responsible?!?! The senior doctors, medical directors who came up with this protocol in the 1st place??? The CEO or chief medical officer who approved & signed off on this protocol?!?!? The infection control team & educators who didn’t educate the ground staff enough, and weren’t vigilant enough in their audits & random spot checks?!?!?! The external audit teams who couldn’t detect any shortcomings & signed off that the staff are following protocol?!?!? The actual ground staff/staff nurses who got careless or bochap or simply burnt out to overlook 100% of the by-the-book steps?!??! How many of these staff nurses??? 1, 2 or the whole lot of them?!?!?

Going by what he says maybe the Health Minister must commit hari-kiti? No wonder only warning letters were issued? And ST is wayanging?

(Related post: GCT believes in Jap values. But not for the elites.)

Seems I was right to ask if ST’s call for a public cyber-lynching of “responsible” staff is a lot of wayang aimed at distracting attention away from those that must take responsibility: the CEO of SGH and the MoH senior officer that delayed reporting the matter to the minister.

“Where does a wise man hide a leaf? In the forest. But what does he do if there is no forest? He grows a forest to hide it in.”― G.K. ChestertonThe Innocence of Father Brown

In this story, Father Brown, an amateur detective, deducted that a commanding officer hid his murder of a fellow-officer by sending his soldiers into battle in the area where the body lay. The dead bodies of the soldiers “covered up” the murder.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

This site uses Akismet to reduce spam. Learn how your comment data is processed.

%d bloggers like this: