<\/span><\/h2>\n\n\n\n\"cirs bayern\" has processed the case in a structured manner, using the London Protocol, as follows.<\/p>\n\n\n\n
3.1. The Core Problem of the Thallium Case<\/h3>\n\n\n\n
Insteaad of thallium(I) acetate, the dispatcher had searched for \"thallous acetate\", which lead to results that did not provide a clue to an imminent danger. According to \"cirs bayern\", the search results, which Google shows, have been adapted, most likely because of an increased number of searches for \"thallium poisoning\". After his search, the dispatcher did not see any necessity to warn the ambulance crew against a hazard.<\/p>\n\n\n\n
3.2. The Faulty Procedure<\/h3>\n\n\n\n
Due to the false indication of quantity, which the caller had provided, and the search result, the ambulance crew was not warned against the danger caused by a hazardous material.<\/p>\n\n\n\n
3.3. Contributory Factors According to the Categories of the London Protocol<\/h3>\n\n\n\n
Organisational and Management Factors:<\/strong><\/p>\n\n\n\nWithout a prioritised direct line to the poison information centre for emergency services and the rescue coordination centre, making contact rapidly was not possible. <\/p>\n\n\n\n
Author\u00b4s note: This call was made by the rescue team in the first place. Possibly, the dispatcher would have called if he had had a direct line to the poison information centre.<\/p>\n\n\n\n
Task and Technology Factors:<\/strong><\/p>\n\n\n\nDispatchers can only obtain limited help from specialists, such as the Analytical Task Force, ATF, on the phone in case of an emergency which involves a hazardous material. Reference books such as the German Red List and the Yellow List (Rote und Gelbe Liste), which are reference works for medications, or the \"GESTIS-Stoffdatenbank\", a database with information on hazardous materials, are not directly accessible via the system which is used to dispatch the rescue teams.<\/p>\n\n\n\n
In addition, the responsibility to teach their staff how to execute such searches lies with the respective rescue coordination centres. There is no uniform regulation which applies throughout Bavaria.<\/p>\n\n\n\n
Work Environment Factors:<\/strong><\/p>\n\n\n\nA rescue coordination centre\u00b4s employees have access to the hazardous substance database Memplex (TM), which does not contain medications, though. As the dispatcher primarily thought of a drug, he performed a general web search.<\/p>\n\n\n\n
Individual Factors:<\/strong><\/p>\n\n\n\nThe caller had mentioned the wrong quantity of \"25 milligrammes\" instead of \"25 grammes\". It is not known whether the dispatcher had checked the plausibility of this indication.<\/p>\n\n\n\n
3.4. The Recommended Intervention Measures<\/h3>\n\n\n\n
The following measures have been suggested by the employees of \"cirs bayern\":<\/strong><\/p>\n\n\n\n