NEWS

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January 12, 2008

Another one bites the dust

In continuing the tradition of rejected New York Times letters, my latest:To The Editor:It is correct to point out that inadequate organization, planning and training in hospitals has led to poor response times and outcomes for cardiac arrests (“Hospitals Seen as Slow to Halt Cardiac Arrest,” news article, Jan. 3). What should also be mentioned is that a ubiquitous lack of standardization in defibrillator model—even within single departments—hampers any training efforts and significantly contributes to poor performance of code teams.Hospitals buy new devices as they are needed and models are decided upon with short-term costs and not always patient care in mind. The result is a smattering of models across a hospital for which proper training—and therefore proper patient care—is impossible. In health care quality jargon, this is a textbook “system error” in which a latent error, benign on its own, exists ready for a well-intentioned code team to trip over it; the system is designed to fail.George L. AnesiCleveland, OH