To the shock of the medical team, a patient opened her eyes on the operating table while being prepped for the organ donation in October 2009. The patient, who had overdosed, was prepped for donation after cardiac death (DCD), despite her scans not meeting brain death requirements. Thankfully, the procedures were stopped prior to any incision.
This webinar goes over the five major breakdowns within the incident using the Cause Mapping method of root cause analysis. The near-miss healthcare case study analysis expands from a 5-Why Cause Map into a more thorough 18-Why Cause Map that shows the different options for mitigating risk in future incidents.