A 71-year-old woman underwent replacement of the ascending aorta for Type A aortic dissection. After 6 years, she suddenly developed severe hemolytic anemia, and a second operation for replacement of the ascending aorta was performed. Her hemolysis was thought to occur as follows: the proximal ascending aorta of the graft might have gradually expanded until it compressed the graft. The severe hemolysis was thought to be attributable to disturbance of blood flow by a jet of blood at the site of constriction or the reversed inner felt. Such a case as this is very unusual in that the second operation for hemolytic anemia occurred 6 years after the first surgery.
Abstract. Our study aim to understand complete picture and issues on medical safety and investigate preventive measures for medical errors by analyzing data captured by bar code system and entered by Personal Digital Assistance. Barcode administration system named Point-of-Act-System was designed to capture every activity at the bed sides. Complete activity data including injection, treatment and other nurses' activity and warning data showing mistakes on injections were used for our analyses. We described the data and analyze statistically by accumulating data by hour to find potentially risky time and understand relationship between business and errors. The warning rate as a whole was 6.1% in average. The result showed there was a negative correlation between number of injections and injection warning rate (-0.48, p<0.05). Warning rate was relatively low in the hours that numbers of administrating injections are high. Bar code administration system is quite effective way not only to prevent medical error at point of care but also improve patient safety with analyses of data captured by them.
A case is presented in which 7 months after the first mitral valve replacement (MVR) the malfunction of a Bjork-Shiley valve prosthesis was supposed and the thrombosed valve prosthesis was 2 months later successfully replaced. For the detection of the malfunction of the valve prosthesis echocardiography was especially useful. Additional Indexing Words: Echocardiography Phonocardiography Anticoagulant therapy Dipyridamole Urokinase JORK-SHILEY valve prosthesis has recently been used widely for its hemodynamical excellences and some serious complications of this prosthesis were reported.1),2) This paper is a report on the thrombosed Bjork-Shiley mitral valve prosthesis. We could detect its malfunction echocardiographically and phonocardiographically and performed the replacement successfully. CASE REPORT A 38-year-old woman was operated upon in February 1974 for severe mitral stenosis. The Bjork-Shiley tilting disc valve (23 MBP) was used for valve replacement of the highly calcified mitral valve. The patient's recovery from MVR was uneventful. The echocardiogram of the first postoperative day showed no remarkable changes. Valve amplitude was 10mm, diastolic descent rate was 20 mm/sec, left atrial dimension was 38mm and no changes were seen in the echo of the mitral annulus (Fig.1). Anticoagulant therapy was started on the third postoperative day with heparin. Since the 5th postoperative day, warfarin and dipyridamole (375mg/day) were given instead of heparin. After her discharge she visited our clinic every 2 weeks
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