Author: patientsafe@icloud.com
Victims Of Essure
AIRWAY CRISIS
Same scenario. 2 different pathways – which are you taking? Scenario: 60yr male arrives to ED in respiratory compromise, previous tracheostomy (now closed over), assaulted by son who’d stamped on his neck and chest fracturing ribs with likely pneumothorax. (Old notes not available at time later reveal previous attempts to […]
BVM: No Expiratory Valve = Very Poor PreOxygenation
Not all Bag Valve Masks are designed the same. One major difference is the presence of an expiratory valve. If your BVM does not have an expiratory valve it will entrain air when used for pre-oxygenation vastly impairing the amount of oxygen delivered to patients. Many staff aren’t aware of […]
Activated Self-warming Blankets
Activated self-warming blankets have several safety advantages over forced-air warmers. They may also represent a significant cost saving measure – linen usage will be greatly reduced. Disadvantages of forced air warmers include: – occasionally remembering to turn forced air warmer on is overlooked – risk of patient burns when used […]
Remove Central Lines Supine
Turn the ‘Remove Central Lines Supine’ animation into your screensaver wallpaper with a clickable link to the animation by following these simple steps. 1. Click on image above and save as a PNG file in pictures folder. 2. For MAC: Go to System Preferences > Desktop and Screensaver > Desktop […]
Oxygen Analysers
Should oxygen analysers become standard in all hospital areas where airway support is provided? A pilot study utility ETO2 monitoring indicated that less than 78% of patients in emergency department resuscitation bays were receiving adequate PreOxygenation prior to induction for intubation. Please feel free to join the conversation by clicking on […]
Team of Teams
Last year the BMJ reported medical error as the third greatest cause of death in healthcare. Does the design of error reporting systems render them powerless to change this? Current systems are designed using a command structure: Command structures have been present for hundreds of years and were used with […]
2. Time To Pull The Andon Cord
One day, some time in the future, a nurse or doctor will notice something – a piece of equipment, the way a drug is packaged, a problem with a system – and she will (metaphorically) pull a cord to sound an alarm. The siren that sounds will be a pleasant […]
1. Paradigm Shift
What you see depends on what you’re conditioned to see: We’ve grown up in healthcare seeing education, policy writing and checklists as the most powerful tools for improvement. Those in the most influential positions are often academically gifted and tend to reinforce this behaviour. Education has served them proud, it […]