IN SEARCH OF THE LOST CORD

SUMMARY
Maria Yvonne Stark was a four year old girl fighting for since the day she was born. Maria was on her
bed in the children’s Hospital in Seattle. The Nurse who was in charge of Maria treated many young
people and had a prior experience of taking care of a dozens of patients every day. The Nurse and the
other staff are working hard so that Maria can overcome Handicap.

Maria was sleeping and the nurse wanted to connect the ECG (Electrocardiography) so that she can
observe girl’s condition at the Nurse station in the down corridor. There is a portable intravenous (IV)
pump beside the ECG which has a similar six pin connector as of heart machine (ECG).

She connected the power cord of IV Pump (Right hand) to the connector of the EGC (Left hand) which in
turn, a lethal current passed through Maria chest and back to IV Pump from the other electrode and
lead attached to her chest. This resulted in giving a fatality to heart which stops the heart pumping. In
spite of giving a cardiopulmonary resuscitation (CPR) after realizing of the mistake done by the nurse
(Human Error), the doctor and staff cannot save the poor girl.

Causes of the Accident:

1. Nurse was in a state of huge emotion change as Maria case was really complicated. She was on
the bed as she was born with a number of significant birth defects. There are pretty many
chances for a person making mistakes if he/she is exposed to extremities of emotions (one
regain to good health easily and other suffer pain even after long term treatment) which causes
distorted thinking patterns.
2. Maybe due to the huge WORK LOAD on the nurse which lead the accident.
3. The ASSORTED cables and lines is one of the reason for accident.
4. Maybe the previous person who was charging IV Pump has disconnected the cord from the
machine end, but not from the socket end and without knowing this the nurse has connected
this to heart machine.

Ways to avoid the accident:

1. The emotion factor can be removed only if we get trained in such hectic situations or get to
know about these kind of errors that happened previously so that we can be more cautious.
2. Work load need to be reduced or frequent gaps between the work (Rest Hours) will refresh
them and focus on their work.
3. The cables should be sorted perfectly, so that there won’t be any confusion in plugging them to
their respective cords.
4. If the cord from IV pump is disconnected from the socket end, the accident might not occur.
5. Checking for twice or thrice whether she’s doing the work in the right way or not. This is a time
consuming thing but there won’t be any accidents if we do so.