Archive for June, 2008

The “man cold”

Friday, June 20th, 2008

With winter setting in now in New Zealand we are prone to an epidemic of that serious condition, the “man cold”.

Is the “Windows Key” a WOMBAT?

Thursday, June 19th, 2008

What is the Windows Key you ask? In that case it’s currently a waste of space on your keyboard. The Windows key sits down on the bottom left corner of your keyboard between the “Ctrl” and “Alt” keys. You’re not using Windows? Well, you’re probably stuck with using a Windows keyboard and a useless key. If you’re a Mac user then you have the Apple Key - and you can smugly know that the Apple key spawned the Windows key.

What does the Windows key do? Press it. It kicks off the Start menu - yes, as some wag (not this kind) pointed out Windows is the operating system where you have to press Start to stop the system.

However, the Windows key has more functions available if you use it in combination with another key on your keyboard. For example, pressing the Windows key and “D” will minimise all the open windows and if you press that combination again it will restore them exactly how they were. Pressing Windows key and “M” will minimise all windows but not restore them.

Uber geeks probably already know that the Windows key plus the “Break” key brings up the System Properties. How memorable and useful is that?

The combination I use frequently is the Windows key plus “E” as this kicks off Windows Explorer showing My Computer.

Here’s the full list of Windows key combinations:

  • Windows key (Display or hide the Start menu)
  • Windows key + BREAK (Display the System Properties dialog box)
  • Windows key + D (Display the desktop - press again to restore windows)
  • Windows key + M (Minimize all of the windows)
  • Windows key + SHIFT + M (Restore the minimized windows)
  • Windows key + E (Open My Computer)
  • Windows key + F (Search for a file or a folder)
  • CTRL + Windows key + F (Search for computers)
  • Windows key + F1 (Display Windows Help)
  • Windows key + L (Lock the keyboard)
  • Windows key + R (Open the Run dialog box)
  • Windows key + U (Open Utility Manager)

If you like using your keyboard instead of your mouse all of the time and you can remember the key combinations you set up, then Winkey is free software that you can easily download and install that allows you to set up other Windows key combinations as you like - like Windows key + W for Word or, as on my computer, Windows key + O for Opera and Windows Key + X for Firefox.

For most people the Windows key isn’t very useful (except for Windows key + E) - but it can be if you like using keyboard shortcuts.

Will these changes prevent a repetition?

Sunday, June 15th, 2008

In my previous post, about the preventable perinatal death I had missed a report on the Stuff website titled “Hospital procedures to change after mother dies“.

According to this report

An internal investigation by Auckland’s District Health Board (ADHB) was launched after Ms Bayliss’ death, and several procedural changes have followed including a new process for obtaining emergency blood and checking all pregnant women for risk of postpartum haemorrhage.

Assuming this was reported correctly, can we be confident that those reported changes will prevent problems in the future and if we look retrospectively would they have resulted in a different outcome?

Firstly, a disclaimer - we’re working off newspaper reports 5 months after the event - but that’s all we have to work with. The report stated that there were “several procedure changes” but nominated only two - we don’t know what the others were, but presumably the most important ones were reported.

A new process for obtaining emergency blood

What “emergency blood” means I don’t know. If it means the putting aside of blood in case of emergency so it is easily and quickly available when required then yes that will be beneficial.

Checking all pregnant women for risk of postpartum haemorrhage

On the face of it this sounds good - but isn’t it happening already? Certainly in the case of Renee Bayliss it would make no difference as she had been checked (on December 31st) and the risk had been identified.

This last recommendation sounds like a typical shallow response to failure. The only way to really address repetitive failure is with rigorous root cause analysis. When a proper root cause analysis is conducted everything related is put on the table as a possible cause. In our experience, whatever is first considered to be the real reason for failure is never the reason.

Given the identified risk that “Her placenta was also found to be at risk of causing problems, including bleeding following birth” did the investigation include analysis of the clinical decision to choose induction instead of Caesarean? Maybe, I’m hypothesising, that was the root cause and all the rest were contributing factors - I don’t know, but to prevent the preventable all options need to be covered.

Prevention of repetitive failure requires more than “investigation” it requires application of a rigorous process - otherwise it just a …

Confident it was an isolated case

Saturday, June 14th, 2008

The Chief Medical Officer at Auckland Hospital claimed a case of preventable death had a combination of circumstances that was unusual and he was confident it was an isolated case. Sounds like code for “it won’t happen again because it’s very unlikely”. That’s not an effective way to deal with repetitive failure - and preventable hospital death in New Zealand is definitely a case of repetitive failure, the national solution to which has been to take seven years to produce an incomplete report.

Auckland City Hospital admitted that the death of Renee Bayliss on January 26 withn 4 1/2 hours of the birth of daughter, who survived, was preventable. The report in the NZ Herald stated, “A first-time mother died from severe bleeding during childbirth after blood was not put aside for her, despite her specific request.”

The most galling aspect of this case was that the risk of haemorrhage was recognised before the commencement of induction and Ms Bayliss had requested cross-matched blood be put aside. That request was made on January 24: it wasn’t needed until January 26 but when it was needed it wasn’t there.

Key issues in care were identified as:

* Why she was not quickly given a transfusion of “universal donor blood”, whose higher risks are considered justifiable, rather than having to wait for blood cross-matched because of particular antibodies that had been injected before the birth. The anti-D antibodies are given if there is a risk of the mother’s immune system attacking the fetus’ blood cells.

* Whether a hysterectomy, to stop the bleeding, should have been done sooner.

The problem with these “key issues” is that they deal with conditions that happened as a consequence of earlier treatment - they do need to be addressed - but the real issues, in my view, are:

  • Number one issue - why was cross-matched blood not delivered until 6:17am on the 26th? (over a 32-hour interval)
  • Why did the patient have to request for blood to be put aside? Isn’t that what doctors are for?
  • On December 31st, “Her placenta was also found to be at risk of causing problems, including bleeding following birth.” Why did this information, of identified higher risk, not ensure that blood was ready and available?
  • Given the known risk of haemorrhage, why was induction started before securing the matched blood? More than three weeks had elapsed since original hospital diagnosis, so it shouldn’t have been an urgent induction.
  • “Although a registrar had asked at 4.15am for cross-matched blood to be provided, the request was not carried out.” Why not?
  • “The blood bank was not told a cross-match of blood was required until 5.20am.” What is happening here? Is there a communication problem with the blood bank? Not forgetting that they were advised of this same need more than 24 hours before.

The hospital has commissioned an external review. Hopefully that will arrive at uncovering the root causes of failure (tough to do after this much delay) - otherwise we will see this kind of preventable death recurring. An external review is better than nothing - but much better would be to have that kind of review happen automatically within hours of the event to ensure that all relevant facts can be gathered while they are available and memories are fresh.

Hospitals should have automatic review and root cause analysis processes built in when serious incidents occur - otherwise combinations of unusual circumstances and “isolated” cases of preventable death will continue to happen.

The very least we can do is to ensure that a preventable death prevents another.

Instant petrol price rises

Wednesday, June 11th, 2008

Why is the petrol price instantly linked to the price of crude oil? There’s at least a three month delay between the time crude oil is purchased and shipped to New Zealand for refining and delivery to your local petrol station. We’re paying for petrol at ~$US140 per barrel when that petrol was refined from oil that cost less than $US100 a barrel.

To make that work with anything else you’d probably need to have a small group of companies that operated like a cartel.  Couldn’t happen in our free-market economy where competition is king.

Have you noticed that (in New Zealand) the petrol price is always some dollar and cents amount followed by .9 cents? No matter the oil price or the exchange rate - it’s always .9 cents. And all the oil companies come up with that exact same price ending in .9 of a cent, every time. Amazing.