Chapter 7
Proactive Root Cause Problem Solving
The Tragic and Preventable Mary McClinton Story
Mary McClinton’s death at Virginia Mason Medical Center (VMMC) (Seattle, Washington) is a well-known patient safety incident. McClinton died in 2004 after being injected with chlorhexidine, an antiseptic solution, instead of a contrast dye. During her procedure, there were three clear liquids that were kept in stainless steel bowls on a tray: the antiseptic, the dye, and a saline solution. Anticipating the interventional radiologist’s need, an experienced technician prelabeled an empty syringe as “contrast dye.” However, he later allegedly filled the syringe with the antiseptic, not the dye.1 A Lean thinker would recognize the potential for systemic ...
