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Toolkit:Safety and Justice/Baffled

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Who's boss when saving lives

Penicillin Allergy.jpg
A nurse intervenes at an operation to check for a possible allergy to penicillin before starting to administer penicillin. Despite the surgeon’s protests, she insists to take the time to check because the information on the intake forms are unclear. It is found that the patient is indeed allergic to penicillin! The nurse has saved the day, but it took bravery to overrule the doctor.

Breakthrough on ulcers

Dr Marshall.jpg
In 1982, when the Heliobacter Pylori bacterium was discovered by Dr Marshall and Dr Warren, stress and lifestyle were considered the major causes of stomach and intestinal ulcers. It is now firmly established that Heliobacter Pylori causes more than 90% of duodenal (intestinal) ulcers and up to 80% of gastric (stomach) ulcers.

Dr Warren, a pathologist from Perth, Australia, paved the way for the breakthrough when he discovered that small curved bacteria colonised the lower part of the stomach in about 50% of patients from which biopsies had been taken. Dr Marshall proved that H. pylori caused gastric inflammation by deliberately infecting himself with the bacterium. The Nobel citation praises the doctors for their tenacity, and willingness to challenge prevailing dogmas. "By using technologies generally available they made an irrefutable case that the bacterium H. pylori is causing disease. By culturing the bacteria they made them amenable to scientific study."

It is thought that H. pylori infection can trigger an ulcer by stimulating increased acid production in the stomach, leading to damage to the stomach or intestinal lining.

Lord May of Oxford, President of the Royal Society, said: "The work by Barry Marshall and Robin Warren produced one of the most radical and important changes in the last 50 years in the perception of a medical condition. Their results led to the recognition that gastric disorders are infectious diseases, and overturned the previous view that they were physiological illnesses."

Landing on Hudson

A320 on Hudson river.jpg
After departure, US Airways Flight 1549, the Airbus A320 ingested several geese and the engines stopped. The captain decided to land on the (icy-cold) river Hudson and made a perfect splash-down. There were no fatalities. The captain was later heralded as hero and received several commendations. Interestingly, capt. Sullenberger (aka 'goose killer'), when he was serving in the Air Force, was a member of an aircraft accident investigation board. It was said that his experience as a glider pilot had helped landing the aircraft safely on the water.

Back to stable

Chlorine plant.jpg
In a Chlorine plant one of the most important safety systems is the Chlorine Destruction Unit. In case of any problem in the process, this unit ensures the safe destruction of chlorine present in the system, avoiding its release into the atmosphere.

This unit is normally constantly kept at a slight under-pressure, thus making sure that chlorine is naturally pulled into the destruction unit, making it a fail-safe system.

During maintenance activities, the panel operator noticed that the under-pressure of the destruction unit reduced, from -20 to -10. If this trend would continue, the system would end up at 0 or over-pressurized, rendering it ineffective. There were people out in the plant doing various activities, and they would also be at risk. The chief operator did not know what caused this problem, but immediately gave the crew instructions to reverse all the actions taken over the past few hours, and to restore the system back to the previously known stable point.

It turned out this was the correct action. It also turned out that the pressure problem was a result of an as-yet unidentified design flaw in the system.