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Qaagi - Book of Why

Causes

Effects

anesthesia providers who were so authorized ( 24.8 %(passive) set bywrong infusion rates

non - anesthesia providers(passive) set bywrong infusion rates

to 4 mL / h(passive) was setInfusion rate

at 0.15(passive) was setInfusion rate

In contrast , medication administration tasks such as administering medication via infusion pumps or intravenous push were found to be susceptible to errors of commission ( egsettingthe wrong infusion rate

inaccurate measurement of fluid length or miscalculation or incorrect rate setting of the device(passive) caused bythe wrong rate of infusion

a single hypersensitivity - type IAR , including one Grade 3 treatment - related anaphylactoid serious adverse event ( SAEresultedfrom an infusion rate error

low titer irregular antibody(passive) caused byinvalid infusion

the physician and(passive) set byinfusion rate

a leaky catheterresultedin an incorrect infusion rate

woman ’s death Authorcauseswoman ’s death Author

woman ’s death - RightDiagnosis.com News »causeswoman ’s death - RightDiagnosis.com News »

falsely elevated pressures 14can causefalsely elevated pressures 14

in a grade 3resultedin a grade 3

to 0.5 - 2 µl per min prevents trauma to the optic nervesetto 0.5 - 2 µl per min prevents trauma to the optic nerve

to potentially dangerous incorrect doses of medications and fluidswill leadto potentially dangerous incorrect doses of medications and fluids

MayCauseMay

to ensure a smooth return to normal and avoid hypoglycemiadesignedto ensure a smooth return to normal and avoid hypoglycemia

to be very lowis setto be very low

meningitis(passive) caused bymeningitis

c.is setc.

extravasation of colloids by effects on hydrostatic pressuremay influenceextravasation of colloids by effects on hydrostatic pressure

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