Video in OR https://www.outpatientsurgery.net/newsletter/eweekly/2017/03/14#2 Wade Ayer – masterminded black box bill. On messenger.
Author: patientsafe@icloud.com
4. The Bystander Effect
In doing nothing we have still made a decision. Bystander Effect: the greater the number of people present, the less likely people are to help. The bystander effect was first demonstrated following the murder of Kitty Genovese in 1964. The New York Times published a report conveying a scene of […]
Central Line Related Air Emboli
Central lines are essential for the care of many patients, however we estimate at least one patient dies worldwide every day from central line related air emboli. The image above is from a CNN report – one of thousands of similar cases. All of these cases are avoidable. Frequently Asked […]
3. Lack of Transparency
Patient safety suffers from a lack of transparency with our incident reporting systems. In healthcare front line staff can’t access valuable information in their error databases. This lack of transparency leaves us flying blind. Without seeing our errors we can’t improve. The repercussions of this are dreadful for patients, families […]
European Medications Agency Suspends Use Of Gadolinium For MRI Scans
2. Ego
‘Senior doctors may actively oppose or denigrate methods which are safer and/or more successful — not just for themselves but for their learners and the system as a whole too — in part because the innovation makes their own deft skill with the old tools less important.’ – Dr Robert […]
Flying Healthcare Safety
Every system is perfectly designed to get the results it achieves. Medical error has been reported as the third greatest cause of hospital death. Despite interventions to overcome this there has been no improvement in medical error rates. Healthcare is perfectly designed for error to be the third greatest cause […]
1. Cognitive Dissonance
What is our great fear in medicine? Hurting people. Not being good enough. And when we change a process for the better it inevitably implies that our PREVIOUS way of doing things was (at least relatively) harmful. To make a minor change for the better, we might have to accept […]
The History of Laryngoscopy
Please click here to see a great review article on the history of laryngoscopy.
Standards for medical device connectors
Recently a tragic mix up where oxygen tubing was connected to a urinary catheter resulted in the death of ex-Socceroo Steve Herczeg (see here). ‘How can anyone make this mistake?’ Unfortunately events like this occur regularly – we often only hear of them via the media – our error report […]