2006 Volume 26 Issue 7 Pages 713-717
Our outpatient clinic was requested by a doctor at the other branch to insert and place a central venous catheter in two patients. The first patient had pancytopenia which worsened over several weeks and wasn't treated for it. The second patient had a blood test and her platelet count fell as compared to the prior 7 days, but her chief physician did not notice it. It was determined that there was a great risk of a fatal complication and the catheterizations were postponed. We may have caused a serious medical accident if we had not confirmed their data in advance, so we reported these cases as examples of safe medical practice. A discussion was held in a risk management committee, and, as a result, a general standard in our hospital was implemented.
