Over the years, a few people have asked me if a Mars Orbiter-type, or
Gimli-type, event could occur in U.S. healthcare. The answer is yes.
It will happen due to a confusion between pounds and kilograms of
patient body weight/mass. Such a sentinel event is required in order to
make the all-metric hospital culture into a JCAHO national patient
safety goal. They won't take my word for it.
Paul
Walter Meier wrote:
Thanks, Pat.
I've read several accounts of this event in the past, but as you said,
this one is truly the best. Hairraising, in fact. And this one does a
far better job of expalining what went wrong with the calculations.
The real problem lay with the fuel density calculations, not with the
calibration of the dripsticks, as the Avweb story reported. Still, it
was the confusion caused by the simultaneous use of two systems of
measurement that nearly led to disaster, and I'm sad to see that
little has changed in the 25 years since.
Cheers,
Walter
On Jan 31, 2008 3:21 PM, Pat Naughtin
<[EMAIL PROTECTED]
<mailto:[EMAIL PROTECTED]>> wrote:
Dear Walter,
The best story that I have read on the Gimli Glider is that by
Wade H. Nelson at:
http://www.wadenelson.com/gimli.html
It is very well written.
Cheers,
Pat Naughtin
PO Box 305 Belmont 3216,
Geelong, Australia
Phone: 61 3 5241 2008
Metric system consultant, writer, and speaker, Pat Naughtin, has
helped thousands of people and hundreds of companies upgrade to
the modern metric system smoothly, quickly, and so economically
that they now save thousands each year when buying, processing, or
selling for their businesses. Pat provides services and resources
for many different trades, crafts, and professions for commercial,
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Google, NASA, NIST, and the metric associations of Canada, the UK,
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On 2008/02/01, at 3:25 AM, Walter Meier wrote:
Greetings all:
The NASA incident on Mars is the one most often remembered for
the danger of using multiple systems of measurement, but this one
is also truly remarkable. Today they're retiring an airplane that
under most circumstances would have been written off many years
ago, so I thought it would be a good occasion to remember the feat.
http://www.avweb.com/eletter/archives/avflash/1043-full.html#197052
Cheers,
Walter
--
Paul Trusten, R.Ph.
Acting Secretary
The Pharmacy Alliance
Midland TX 79707-2872 USA
+1(432)528-7724
mailto:[EMAIL PROTECTED]
http://health.groups.yahoo.com/group/ThePharmacyAlliance
