The Pediatric Cardiac Surgery Inquest Report

 

 

Table of Contents

Chapter 10

Findings and Recommendations


Introduction
The loss and recruitment of program staff before 1994

Loss and recruitment of program staff
The compensation paid to pediatric cardiac surgeons


Problems within the Pediatric Cardiac Surgery Program

Unclear lines of authority
The responsibility of department heads
The responsibility of Dr. Jonah Odim and Dr. Niels Giddins for the events of 1994
Misusing the concept of a 'learning curve'
Administrative issues
Inappropriate staffing levels

Treatment of nurses
Treatment of the families

The issue of informed consent
The experience of the surgeon and the team
Information about surgical risk
Information about the May 17 withdrawal of services by the anaesthetists
Information about the Williams and Roy Report and the February 1995 suspension of the program
Funding for the families
Compensation

Monitoring of issues and problems within and outside the HSC

Monitoring within the HSC
Monitoring outside the HSC

Human and medical error

Error, accident and humanity
Dealing with human error
Blaming
Learning from human error
The investigation of human error
Hierarchy of the effects of error
The importance of early reaction to error
Human factors analysis
A new approach to the handling of medical error at the HSC
Quality assurance
Risk management
The integration of quality assurance and risk management
Critical incident review policy
Team performance

The future of pediatric cardiac surgery in Manitoba

Combining the ICUs

Referral to the College of Physicians and Surgeons of Manitoba
Conclusion
 

  

Current Home - Table of Contents - Chapter 10
Section 1 Chapter 1 - Introduction to the Issues
  Chapter 2 - Pediatric Cardiac Issues
  Chapter 3 - The Diagnosis of Pediatric Heart Defects and their Surgical Treatment
  Chapter 4 - The Health Sciences Centre
Section 2 Chapter 5 - Pediatric Cardiac Surgery in Winnipeg 1950-1993
  Chapter 6 - The Restart of Pediatric Cardiac Surgery in 1994
January 1, 1994 to May 17, 1994
  Chapter 7 - The Slowdown
May 17 to September 1994
  Chapter 8 - Events Leading to the Suspension of the Program
September 7, 1994 to December 23, 1994
  Chapter 9 - 1995 - The Aftermath of the Shutdown
January to March, 1995
Section 3 Chapter 10 - Findings and Recommendations
Appendix 1 - Glossary of terms used in this report
Appendix 2 - Parties to the Proceedings and counsel
Appendix 3 - List of witnesses and dates of testimony
Diagrams
Tables
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