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Lean Hospitals, 3rd Edition by Mark Graban

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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 ...

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