‘Breach In Protocol’ Leads To Latest Ebola Diagnosis « CBS Dallas / Fort Worth.
Reality check…
It is impossible for every person to follow every protocol perfectly every time. The only thing you can be certain of is that at some point there will be a failure at a protocol weak point or that there will be a breach of protocol. These protocols do not eliminate the risk of infection, they reduce it.
This is a fundamental precept of risk analysis. If they haven’t taken this into account, they are idiots.
You might not make the mistake, but someone will. And after 30+ years in the healthcare business, it seems that “the” mistake is made by someone who is certain they wouldn’t make a mistake. Or a piece of equipment or protective gear fails.
One of the things I’ve had to plan on when designing class 3 medical devices is that someone is going to make a mistake. You design against it, but even in the best case the mitigation can only reach the probability of occurrence is “indistinguishable from zero.” I.e. it is still considered a risk that can – and usually ends up – happening.
Never underestimate the ability of people to screw up the best laid plan.