Anyone can report into the PatientSafe Network – simply enter a comment below. If you would like to report anonymously enter your name as ‘anonymous’. Your email address will not be published. Please avoid using any patient, staff or institution identifying details. You can directly report into a specific project […]
Author: patientsafe@icloud.com
Fixing Healthcare Safety
Video & Direct Laryngoscopy
Devices allowing simultaneous video & direct laryngoscopy represent a safety advantage over either direct laryngoscopes or video laryngoscopes. Intubation is more likely to be successful, with less airway trauma. The first attempt at intubation should be the best (and ideally the only) attempt. Laryngoscopes offering the combination of direct & […]
Gas Pipeline Mix Up
Human factors engineering teaches us that despite our best efforts accidental gas pipeline crossovers will persist. We need to focus on putting measured in place such that when these inevitable pipeline crossovers occur they do not lead to patient harm. For information see this link: https://wordpress.com/post/patientsafe.wordpress.com/5027 Help: We are looking […]
Sugammadex Availability
Immediate availability of a box of Sugammadex in every theatre anaesthetic trolley offers an increased level of patient safety. Cost is often used as an excuse by many departments for not doing this however several economic trials have demonstrated that the increased patient safety it affords actually leads to decreased […]
Recall Old Draeger APL Valves
The Draeger anaesthetic machine has a poorly understood issue with its APL valve. When lifted it is actually open – even though it appears closed – creating an inability to pressurise the breathing circuit. Progress: The CEO of Dreager in Germany, Mr Stefan Draeger, had kindly contacted us directly ensuring […]
Ban Indistinct Chlorhexidine
Indistinct chlorhexidine (circled) is easily mistaken for colourless solutions. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost. Watch ‘Gina’s Story’ to see how arterial injection resulted in leg […]
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 (see here). All of these cases are avoidable. They tend to occur from: 1. Accidental line disconnections 2. During line removal if patients […]