Big Mistake in Operating Room, Patient Dead

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In summary, a medical accident occurred in Russia where a formalin solution was mistakenly introduced into a patient's abdomen, causing denaturation and death of cells. This situation is reminiscent of a similar incident involving gluteraldehyde being used in a brain, and highlights the importance of learning from mistakes and improving processes in the medical field. Suggestions such as using specially colored containers for fixatives in the operating room may help prevent future accidents.
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BillTre
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The patent in Russia being operated on for ovarian cysts had a formalin (37% formaldehyde solution) mistakenly introduced into her abdomen.
It was washed out when the mistake was recognized, but ultimately, too late.

Formaldehyde is used for many things, in biology it is often used to fix tissues. It covalently bonds to nitrogen in proteins, either drastically altering their structure of double bonding with adjacent proteins. This causes the proteins to become denatured, non-functional, and precipitate (fixing their location, thus fixing the protein, ). It results in dead cells.

This reminds me of a similar (difficult to forget) story I read about long ago when I was in graduate school. In this case, gluteraldehyde (a stronger, better cross linker than formaldehyde, good for doing histology) was put into someone's brain and fixed their brain while leaving the rest of the body OK (with mechanical assistance).
 
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Link to article?
 
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Didn't work for some reason.
Here it is.
 
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It's always sad to hear about medical mistakes.

One thing I've noticed in recent years, at least in my neck of the woods, is a shift towards a culture of learning from mistakes like this - investigations with attempts to identify root causes and ultimately improve processes. I mean, I'm sure that's always been there to one extent or another, but sometimes with situations like this people can instinctively start to look for someone to blame and miss opportunities to revise their system.
 
  • #5
Like only put fixatives in specially colored containers in the OR?
 

What is a "Big Mistake in Operating Room"?

A "Big Mistake in Operating Room" refers to a serious error or mishap that occurs during a surgical procedure in a hospital or medical setting. This can range from a wrong medication or dosage being administered to the wrong body part being operated on, and can result in severe consequences for the patient.

What are some common examples of "Big Mistakes in Operating Room"?

Some common examples of "Big Mistakes in Operating Room" include wrong-site surgery, leaving surgical instruments or foreign objects inside the patient's body, and administering the wrong medication or dosage. These mistakes can have serious consequences for the patient, including injury or death.

What causes "Big Mistakes in Operating Room" to occur?

"Big Mistakes in Operating Room" can occur due to a variety of reasons, including miscommunication among medical staff, fatigue or burnout of healthcare workers, distractions during surgery, inadequate training or experience, and equipment malfunctions. These mistakes can also be a result of systemic issues within the healthcare system.

How can "Big Mistakes in Operating Room" be prevented?

Preventing "Big Mistakes in Operating Room" requires a multi-faceted approach, including clear communication among medical staff, thorough pre-operative planning and verification processes, proper training and supervision of healthcare workers, and regular equipment maintenance and checks. It is also important for hospitals and medical facilities to have protocols in place for reporting and addressing mistakes when they do occur.

What are the consequences of "Big Mistakes in Operating Room" for the patient and medical staff?

The consequences of "Big Mistakes in Operating Room" can be devastating for both the patient and medical staff involved. For the patient, it can result in serious injury or even death. For medical staff, it can lead to legal and professional consequences, as well as emotional distress and trauma. These mistakes can also have a negative impact on the reputation and trust of the healthcare facility and its staff.

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