Muhimbili (MOI): Sakata la Upasuaji Kichwa na Mguu.

[Kisambuka]

Kama mwana JF natoa pole kwa masikitiko makubwa.Kinachonishangaza tu ni suala la hizi tume.Labda ni utaratibu tu wa serikali, lakini usipofanya mambo kuwa magumu, ni wazi wauguzi waliompotosha daktari ndio wangeshughulikiwa.Sjafahamu kama wamechukuliwa hatua gani zaidi ya kujua aliyechukuliwa hatua ni daktari mhusika.Asante

 

[Mkenya]

Poleni Sana Ndugu zangu. jambo la kuhuzunisha kweli...

Pengine tungewasaidia hao Emanuels hapa kenya,

Tafadhali mlete Emmanuel Didas hapa....URGENTLY atibiwe..

http://www.karenhospital.org/
http://www.nairobihospital.org/default.asp
http://www.agakhanhospitals.org/nairobi/index.asp

Tanzanian surgery mix-up man dies




DAR ES SALAAM, Monday

A Tanzanian man who had a knee operation when he had a tumour in his brain, has died after finally having the operation he required.

Mr Emmanuel Mgaya, 19, died hours after the surgery, performed two weeks late.

Meanwhile, Mr Emmanuel Didas, 20, who had brain surgery although his complaint was in the knee, is slowly recovering but he remains partially paralysed.

The government has apologised for the mix-up, which has been blamed on both men having the same first name.

Mr Didas cannot move his right side following the unnecessary operation.

He said in hospital that he was able to eat his favourite food again – maize meal with fish and vegetables.

Health Minister David Mwakyusa said a commission has been set up to investigate the saga and pledged to send Mr Didas to India for specialised treatment.

He originally hurt his leg in a motorbike accident.

Treatment in India

Mr Mgaya was also due to have treatment in India but died before this was possible.

He spent four days at the Muhimbili hospital's intensive care unit in Dar es Salaam but his condition got worse on Thursday.

He was operated on but died several hours later. His family say they are not planning to sue the government – they always knew he only had a 50 per cent chance of survival, as the tumour had grown so large. He first sought medical treatment, complaining of migraines.

But they have urged the health ministry to employ qualified and compassionate medical staff.

Agencies

 

[salome]

MOI washenzi sana. Hata mama yangu wamemtia kilema cha mguu cha maisha tena baada ya kulipa mamilioni ya pesa kwa ajili ya kufanyiwa operation ya kuunga mguu wake uliovunjika kwenye kiwiko cha mguu. Baada ya operation hiyo ambayo mpaka sasa ni miaka mitatu, mguu bado unauma na Mama anachechemea kwa sababu umekuwa mfupi. Kuna daktari mshenzi sana pale MOI anaitwa MCHARO. Ana majibu ya kejeli sana. Baada ya kumfanyia operation, hakuangaika naye tena wala kufuatilia kwa karibu kujua nini kinaendelea. Hata tulipokuwa tukimfuata, alitupiga chenga na siku tukifanikiwa kumuona, jibu litakalotoka mdomoni mwake, utatamani usingeenda hospitali. Tunajuta kwa nini hatukwenda CCBRT kwani kule wako very keen na wanajali wagonjwa. Imagine, MOI tumelipa 1,300,000/= by then 2004, na mtu amekuwa kilema wakati kule CCBRT gharama si zaidi ya 350,000/= mgonjwa wako anapata huduma safi. Nawashauri wagonjwa wote wa mifupa waende CCBRT kupata huduma nzuri kwa wale Wajerumani na kuachana na hao wauaji wa MOI.

 

[Nyani Ngabu]

Hospital fined for wrong-side surgery Mon Nov 26, 11:04 PM ET



PROVIDENCE, R.I. - Rhode Island Hospital was fined $50,000 and reprimanded by the state Department of Health Monday after its third instance this year of a doctor performing brain surgery in the wrong side of a patient's head.

ADVERTISEMENT

"We are extremely concerned about this continuing pattern," Director of Health David R. Gifford said in a written statement. "While the hospital has made improvements in the operating room, they have not extended these changes to the rest of the hospital."

The most recent case happened Friday when, according to the health department, the chief resident started brain surgery on the wrong side of an 82-year-old patient's head. The patient was OK, the health department and hospital said.

In February, a different doctor performed neurosurgery on the wrong side of another patient's head, said Andrea Bagnall-Degos, a health department spokeswoman. That patient was also OK, she said.

But in August, a patient died a few weeks after a third doctor performed brain surgery on the wrong side of his head. That surgery prompted the state to order the hospital to take a series of steps to ensure such a mistake would not happen again, including an independent review of its neurosurgery practices and better verification from doctors of surgery plans.

In a written statement, Rhode Island Hospital said it was working with the Department of Health to minimize the risk of medical errors.

"We are committed to continuing to evaluate and implement changes to our policies to help ensure these human errors are caught before they reach the patient," the statement read.

The hospital said it was re-evaluating its training and policies, providing more oversight, giving nursing staff the power to ensure procedures are followed, and other steps.

In addition to the fine, the state ordered the hospital to develop a neurosurgery checklist that includes information about the location of the surgery and a patient's medical history, and to put in place a plan to train staff on the new checklist.

The Board of Medical Licensure and Discipline and Board of Nursing is also investigating.

 

[Kithuku]

Wrong side of the head is more explainable than mistaking the knee for the head! These guys might have made mistakes labeling the scans (hence R instead of L) during radio-imaging (this is what a doctor friend is telling me).

 

[Mzee Mwanakijiji]

Kithuku.. kesi ya Muhimbili siyo kuchanga mguu na kichwa; walichanganya wagonjwa. Yaani mgonjwa aliyekuwa na tatizo la kichwa ndiyo alifanyiwa upasuaji wa mguu na yule wa mguu ule wa kichwa. Vinginevyo, kila mmoja wao alifanyia upasuaji ule waliodhania "anastahili". Nadhani hapa ndio watu wamemiss point ya sakata la Muhimbili. Ni kuchanganya wagonjwa ndiko kulikosababisha makosa hayo. So, kama ingekuwa ni mgonjwa yule yule amefanyiwa upasuaji kiungo kisichohusika basi nadhani ingezua maswali zaidi kuliko kuchanganya majina ya Emmanuel na Emmanuel...

 

[Kitila Mkumbo]

Kithuku.. kesi ya Muhimbili siyo kuchanga mguu na kichwa; walichanganya wagonjwa.

And it is this that makes the Muhimbili case disturbingly and foolishly unique! Mgonjwa wa kichwa anachanganywa na mgonjwa wa mguu! It is indefensible!

 

[Mzee Mwanakijiji]

Kitila, that is not it... siyo mgonjwa wa kichwa anachanganywa na mgonjwa wa mguu; walichochanganya ni majina kwanza: Kwa mfano ukiwa na wagonjwa wawili na wote majina yao ni "Ramadhani Robert" na mwingine ni "Ramadhani Robinson" na wote wanatakiwa kufanyiwa upasuaji siku hiyo hiyo; na wamelazwa vyumba vya karibu karibu; Aneyetumwa kwenda kuchukua mgonjwa aitwaye "Ramadhani Robert" bila yeye kujua kuwa kuna mgonjwa mwingine aitwaye Ramadhani Robinson kweny wodi hiyo hiyo na anapoingia tu anaona mgonjwa mwenye jina la "Ramadhani Robinson" na anatakiwa kufanyiwa upasuaji, basi yeye anamchukua na kumleta theater; wale watheater wanafuata taratibu zao na kusema ha! huyo "Ramadhani Robert" anatakiwa kufanyiwa operesheni ya mguu na wanamuandaa kwa upasuaji huo na wakimaliza wanamtuma mwingine kumleta yule mgonjwa mwingine na upasuaji unaendelea; Madaktari wanaamini kuwa wamefanya upasuaji kwa watu wanaostahili.

Tatizo linakuja wakati ndugu wanakuja kuleta thermos ya chai ya maziwa, chupa za mirinda, viazi vya "kizungu" na nguo za kubadilisha. Wanaingia na kukuta mgonjwa wao wa kichwa ana jeraha mguuni! hapo ndipo kasheshe linapoanza...

 

[Nyani Ngabu]

Nadhani kosa la Muhimbili liko defensible. Ni rahisi sana kuchanganya majina. Mfano mwingine ni ktk kesi za uhalifu. Mara kibao watu hudhaniwa wao kuwa ndio wahalifu wanaotafutwa kwa vile tu majina yao yanafanana na jambazi ambalo linatafutwa wakati ukweli ni kwamba ni majina tu yanayofanana lakini ni watu tofauti. Mpaka mtu uje ku-establish kwamba sio wewe unayetafutwa saa nyingine unakuwa umeshasota hata rumande. So mambo ya mistaken identity na mixed identities yanatokea sana ktk sehemu mbalimbali na yanaeleweka.

 

[Tundapori]

Kitila, that is not it... siyo mgonjwa wa kichwa anachanganywa na mgonjwa wa mguu; walichochanganya ni majina kwanza: Kwa mfano ukiwa na wagonjwa wawili na wote majina yao ni "Ramadhani Robert" na mwingine ni "Ramadhani Robinson" na wote wanatakiwa kufanyiwa upasuaji siku hiyo hiyo; na wamelazwa vyumba vya karibu karibu; Aneyetumwa kwenda kuchukua mgonjwa aitwaye "Ramadhani Robert" bila yeye kujua kuwa kuna mgonjwa mwingine aitwaye Ramadhani Robinson kweny wodi hiyo hiyo na anapoingia tu anaona mgonjwa mwenye jina la "Ramadhani Robinson" na anatakiwa kufanyiwa upasuaji, basi yeye anamchukua na kumleta theater; wale watheater wanafuata taratibu zao na kusema ha! huyo "Ramadhani Robert" anatakiwa kufanyiwa operesheni ya mguu na wanamuandaa kwa upasuaji huo na wakimaliza wanamtuma mwingine kumleta yule mgonjwa mwingine na upasuaji unaendelea; Madaktari wanaamini kuwa wamefanya upasuaji kwa watu wanaostahili.

Tatizo linakuja wakati ndugu wanakuja kuleta thermos ya chai ya maziwa, chupa za mirinda, viazi vya "kizungu" na nguo za kubadilisha. Wanaingia na kukuta mgonjwa wao wa kichwa ana jeraha mguuni! hapo ndipo kasheshe linapoanza...

Hodi hodi wajameni,

Vifuatavyo ni mojawapo ya vipengele muhimu sana katika kutofautisha wagonjwa wawili wanapokuwa majina yao yamefanana.
-Tarehe za kuzaliwa.
-Namba ya jarada (faili)la kila mgonjwa.
-Anwani ya anakoishi/anakotoka ya kila mgonjwa.
-Sehemu inayofanyiwa operesheni inakiwa iwekewe alama e.g goti la kulia au kushoto na hata kichwa kinyolewe kama ni operesheni ya kichwa.
-Daktari anayemfanyia operesheni mgonjwa awe ni yule anayemfahamu kimatibabu kabla ya operesheni, isipokuwa labda kama ni operesheni ya dharura daktari wa zamu ndo anaweza fanya operesheni.
-Kukabidhiana kwa mgonjwa kunapitia hatua mbalimbali na watu mbalimbali ambapo wote wanatakiwa kucheki hizo details hapo juu.

Kwahiyo huu ni udhaifu mkubwa sana umejitokeza.
Sisi wabongo vitu vinavyotuzubaisha mpaka tunakabidhiwa cheki zilizokosewa ni:
*Kutokuwa makini.
*Purukushani za kufukuzia mshiko toka kwa mgonjwa.
*Ukilitimba usio na manufaa.

Mungu awe nasi.

 

[Mzee Mwanakijiji]

Nyani, exactly.. tatizo lililoonekana Muhimbili ni kukosa mechanism ya kusimamia mgonjwa toka anapoingia hadi anapofanyiwa upasuaji. Kwa mfano, badala ya kutumia majina namna hiyo, wangetumia namba na hizo namba siyo tu ziko kwenye kitanda bali pia mkononi kwa mgonjwa mwenyewe na kabla hajafanyiwa upasuaji daktari wake lazima ahakikishe ndiye mgonjwa mwenyewe. Haya ya kuingia wodini na nesi kuuliza tu "Immanuel ni nani".. inakuwa kasheshe. Ndio maana reaction yangu ya kwanza kabisa niliposikia habari hii nilisema; it is not as worse as we have seen in more developed countries. Ndiyo maana utaona hapa ni rahisi zaidi kuchanganya viungo kuliko mtu mwenyewe...

 

[Hume]

Nyani, exactly.. tatizo lililoonekana Muhimbili ni kukosa mechanism ya kusimamia mgonjwa toka anapoingia hadi anapofanyiwa upasuaji. Kwa mfano, badala ya kutumia majina namna hiyo, wangetumia namba na hizo namba siyo tu ziko kwenye kitanda bali pia mkononi kwa mgonjwa mwenyewe na kabla hajafanyiwa upasuaji daktari wake lazima ahakikishe ndiye mgonjwa mwenyewe. Haya ya kuingia wodini na nesi kuuliza tu "Immanuel ni nani".. inakuwa kasheshe. Ndio maana reaction yangu ya kwanza kabisa niliposikia habari hii nilisema; it is not as worse as we have seen in more developed countries. Ndiyo maana utaona hapa ni rahisi zaidi kuchanganya viungo kuliko mtu mwenyewe...

Wanasema, we learn through mistake.
Baada ya sakata hili, ushauri huu utaanza kutumiwa soon.

Let wait & see!

 

[Tundapori]

Hodi hodi wajameni,

Vifuatavyo ni mojawapo ya vipengele muhimu sana katika kutofautisha wagonjwa wawili wanapokuwa majina yao yamefanana.
-Tarehe za kuzaliwa.
-Namba ya jarada (faili)la kila mgonjwa.
-Anwani ya anakoishi/anakotoka ya kila mgonjwa.
-Sehemu inayofanyiwa operesheni inakiwa iwekewe alama e.g goti la kulia au kushoto na hata kichwa kinyolewe kama ni operesheni ya kichwa.
-Daktari anayemfanyia operesheni mgonjwa awe ni yule anayemfahamu kimatibabu kabla ya operesheni, isipokuwa labda kama ni operesheni ya dharura daktari wa zamu ndo anaweza fanya operesheni.
-Kukabidhiana kwa mgonjwa kunapitia hatua mbalimbali na watu mbalimbali ambapo wote wanatakiwa kucheki hizo details hapo juu.

Kwahiyo huu ni udhaifu mkubwa sana umejitokeza.
Sisi wabongo vitu vinavyotuzubaisha mpaka tunakabidhiwa cheki zilizokosewa ni:
*Kutokuwa makini.
*Purukushani za kufukuzia mshiko toka kwa mgonjwa.
*Ukilitimba usio na manufaa.

Mungu awe nasi.

Mzee Mwanakijiji,
Naomba urejee hapo juu ili usome vipengele nilivyoviandika vinavyotumika inapotokea majina mawili yakafanana.
Mfano, mmoja anaitwa "Masanja Mkandamizaji" na mgonjwa wa pili anaitwa "Masanja Mkandamizaji".
Nafikiri haya majina yanafanana kwa kila hali kuliko Ramadhani Robert na Ramadhani Robinson!

Kitu kingine ambacho kinasaidiaga katika kutofautisha wagonjwa wa namna hiyo ni kuweka sitika nyekundu katika kila faili la wagonjwa ambao majina yao yanafanana.
Nakuandika kinote "jina la mgonjwa huyu linafanana na jina la mgonjwa mwingine".

Daktari/Nesi akiona stika nyekundu kwenye faili la mgonjwa hata kama alikuwa anajisikia kusinziasinzia itabidi aamke zaidi!

Vilevile kila mgonjwa anatakiwa awe na wrist band yenye patient's particulars zinazoligana naza kwenye faili lake.

Vilevile kitu kinachonihangaisha zaidi ni huyu mgonjwa aliyetakiwa kufanyiwa operesheni ya Kichwa.
Kama ni upasuaji mkubwa wa kichwa kawaida mojawapo ya maandalizi ya mgonjwa ni kunyolewa nywele zote kichwani! na maandalizi haya kikawaida yanafanyika wodini.

Je, ina maana huyu mgonjwa alinyolewa baada ya kupigwa dawa ya nusu kaputi akiwa thieta?
Au kama alinyolewa wodini, je, ina maana alikuwa amelala usingizini wakati wembe unapita kichwani mwake? ama kweli alikuwa kwenye njozi nzito!!! Ila natoa pole zangu kwa mgonjwa.

Ila nakubaliana na wengi kuwa makosa huwa yanafanyika, mfano mgonjwa anatakiwa afanyiwe upasuaji goti la kulia na badala yake makosa yanafanyika anafanyiwa goti la kushoto.

Kwenye hospitali za kibongo ukitoka mzima wewe shukuru Mungu.

"Mimi naona kitu cha muhimu kabisa kufanya kama bahati mbaya ukiuugua ni kwenda South Afrika,UK,USA, China na India"

Mungu awe Nasi.

 

[tz_devil]

Kuna kitu kinaitwa "Name Alert" katika hospitali za wenzetu. Daktari akiona "Name Alert" kwa mgonjwa kuna procedures anatakiwa afuate kuepuka kuchanganya wagonjwa. Lakini, inaelekea sisi hatuna hii kitu au kiburi chetu kazini.

 

[Mwafrika wa Kike]

Kuna kitu kinaitwa "Name Alert" katika hospitali za wenzetu. Daktari akiona "Name Alert" kwa mgonjwa kuna procedures anatakiwa afuate kuepuka kuchanganya wagonjwa.

Kabisaa,

Name alert lazima itumike ukichukulia wengine ukoo mzima unatumia jina moja tu!

Huko bongo kweli inabidi MUNGU tu aingilie kati jamani!

 

[Kalamu]

Mzee Mwanakijiji,
Naomba urejee hapo juu ili usome vipengele nilivyoviandika vinavyotumika inapotokea majina mawili yakafanana.
Mfano, mmoja anaitwa "Masanja Mkandamizaji" na mgonjwa wa pili anaitwa "Masanja Mkandamizaji".
Nafikiri haya majina yanafanana kwa kila hali kuliko Ramadhani Robert na Ramadhani Robinson!

Kitu kingine ambacho kinasaidiaga katika kutofautisha wagonjwa wa namna hiyo ni kuweka sitika nyekundu katika kila faili la wagonjwa ambao majina yao yanafanana.
Nakuandika kinote "jina la mgonjwa huyu linafanana na jina la mgonjwa mwingine".

Daktari/Nesi akiona stika nyekundu kwenye faili la mgonjwa hata kama alikuwa anajisikia kusinziasinzia itabidi aamke zaidi!

Vilevile kila mgonjwa anatakiwa awe na wrist band yenye patient's particulars zinazoligana naza kwenye faili lake.

Vilevile kitu kinachonihangaisha zaidi ni huyu mgonjwa aliyetakiwa kufanyiwa operesheni ya Kichwa.
Kama ni upasuaji mkubwa wa kichwa kawaida mojawapo ya maandalizi ya mgonjwa ni kunyolewa nywele zote kichwani! na maandalizi haya kikawaida yanafanyika wodini.

Je, ina maana huyu mgonjwa alinyolewa baada ya kupigwa dawa ya nusu kaputi akiwa thieta?
Au kama alinyolewa wodini, je, ina maana alikuwa amelala usingizini wakati wembe unapita kichwani mwake? ama kweli alikuwa kwenye njozi nzito!!! Ila natoa pole zangu kwa mgonjwa.

Ila nakubaliana na wengi kuwa makosa huwa yanafanyika, mfano mgonjwa anatakiwa afanyiwe upasuaji goti la kulia na badala yake makosa yanafanyika anafanyiwa goti la kushoto.

Kwenye hospitali za kibongo ukitoka mzima wewe shukuru Mungu.

"Mimi naona kitu cha muhimu kabisa kufanya kama bahati mbaya ukiuugua ni kwenda South Afrika,UK,USA, China na India"

Mungu awe Nasi.

Chombachomba:
Umeelezea vizuri taratibu ambazo hutakiwa kuzifuata ili kupunguza makosa hatari kama hili lililotokea Muhimbili; na ninayo hakika kuwa hospitali kubwa kama hiyo taratibu hizo wanzo, na walitakiwa kuzifuata. Hapa ni uzembe na kutofuata taratibu zilizowekwa sababu ya kutokea makosa namna hii.

Makosa makubwa kama haya hata huko majuu yalikuwa yanatokea mara nyingi sana, na ndio sababu pakawepo na asasi kama JCAHO (Joint Commission of Accreditation of Health Care Organizations), ambayo ni kama (TBS ya vipimo kwetu hapa) ili kuhakikisha kuwa taratibu za matibabu zinafuatwa, na kama kuna kukiukwa, "Accreditation" ya hiyo hospitali inafutwa.

Ili kupunguza makosa na kuhakikisha kila mgonjwa anatambulika, anapoingia tu hospitalini anavalishwa 'mkanda' wenye alama (namba ya digital) ya kumtambulisha yeye binafsi, na sio jina pekee. Hii sio technology wanayoshindwa kuwa nayo sehemu kama Mhimbili, kwani ni hiyo hiyo inayotumika pale kwenye 'cash' machine hata kwenye 'grocery' store za huko.

Kupunguza matatizo ya namna hii yasiendelee kutokea (na yapo mengi mno, na hata yanayosababisha vifo bila watu kujua, kwa mfano kutumia dawa ambazo hazikuwa za mgonjwa aliyehusika), ni lazima pawepo chombo kinachojitegemea kinachohakikisha kuwa standards zinafuatwa; yaani an Accrediting Body ya hizo sehemu zinazohusika na matibabu ya wagonjwa.

 

[Kitila Mkumbo]

Kitila, that is not it... siyo mgonjwa wa kichwa anachanganywa na mgonjwa wa mguu; walichochanganya ni majina kwanza: Kwa mfano ukiwa na wagonjwa wawili na wote majina yao ni "Ramadhani Robert" na mwingine ni "Ramadhani Robinson" na wote wanatakiwa kufanyiwa upasuaji siku hiyo hiyo; na wamelazwa vyumba vya karibu karibu; Aneyetumwa kwenda kuchukua mgonjwa aitwaye "Ramadhani Robert" bila yeye kujua kuwa kuna mgonjwa mwingine aitwaye Ramadhani Robinson kweny wodi hiyo hiyo na anapoingia tu anaona mgonjwa mwenye jina la "Ramadhani Robinson" na anatakiwa kufanyiwa upasuaji, basi yeye anamchukua na kumleta theater; wale watheater wanafuata taratibu zao na kusema ha! huyo "Ramadhani Robert" anatakiwa kufanyiwa operesheni ya mguu na wanamuandaa kwa upasuaji huo na wakimaliza wanamtuma mwingine kumleta yule mgonjwa mwingine na upasuaji unaendelea; Madaktari wanaamini kuwa wamefanya upasuaji kwa watu wanaostahili.

Tatizo linakuja wakati ndugu wanakuja kuleta thermos ya chai ya maziwa, chupa za mirinda, viazi vya "kizungu" na nguo za kubadilisha. Wanaingia na kukuta mgonjwa wao wa kichwa ana jeraha mguuni! hapo ndipo kasheshe linapoanza...

Mwanakijiji: Mimi ni mwalimu, hata kwenye kusahihisha mitihani tu ambalo sio jambo linalohatarisha maisha, hatufanya uzembe na ujinga kwa kiwango hicho. Siwezi ku-pick karatasi ya mwanafunzi na kujaza maksi kwenye black na red sheet bila kuangalia exam number, reg no., degree programme na mwaka anaosoma. Vinginevyo, watu wengi sana wangekuwa wanapata marks zisizo zao. Vivyo hivyo, siwezi kumsamehe daktari na nesi aliyesomea kazi yake miaka nenda rudi kufanya kosa kubwa kama hilo eti alichanganya majina. Patient and medical records is a whole course in medicine, na ninajua hawa wote wanajua sana mambo haya. hapa kilichofanyika ni gross negligence and they must take responsibility to send a strong message to others and especiially to the incoming generation of doctors and nurses. For sure, the mistake they did is only punishable rather inexcusable.

 

[Nyani Ngabu]

Kitila, one thing you are forgetting is that none of is infallible. We are all capable of making mistakes no matter who/ what we are. My friend, accidents will happen.

 

[Mzee Mwanakijiji]

Kitila, kuna makosa ya kibinadamu na makosa ya kizembe; Mahali fulani katika sakata hili, makosa hayo mawili yaliingiliana. Unaweza kuweka kinga zote ambazo mwanadamu anaweza kuzifikiria and somewhere just a single mistake inaweza kumkosesha mtu. Lakini kutoa adhabu kali kama "funzo" inaweza kuwa ni over reacting. Kuna watu ambao wamefanya makosa mengi na yenye athari kwa watu wengi zaidi kuliko makosa ya madaktari hawa; la maana ni kuhakikisha kuwa tukio kama hilo linapewa nafasi ya kutokea kila baada ya miaka 100! Kusema kuwa halitatokea tena ni kujidanganya. Na kama walivyosema wengine liwe funzo kuwa we shouldn't take anything for granted.

 

[Kafara]

kuna kitu kinaitwa bahati mbaya/ajali (accident) na uzembe. katika hili nadhani kuna mahali pamefanyika uzembe na si lazima kwamba uzembe huo kafanya daktari. uzembe huo ndio ukachochoe mtiririko wa makosa katika hatua zote zilizofuata hadi upasuaji ulipofanyika.

aidha hii inawezekana ikawa ni ufunuo wa jinsi watu wanavyofanyakazi kwa mazoea na kuamini kwamba "kama fulani kapitia faili basi kila kitu ni sahihi" bila ya yeye pia kulipitia na kuhakiki kwamba kila kitu ni shwari.