Obstacles To Patient Safety
Chlorhexidine – TGA letter?
This is a letter we wish the TGA will write: The TGA has made the decision to ban indistinct pourable chlorhexidine solutions. This decision is in keeping with recommendations from the root cause analysis (RCA) performed after the accidental epidural injection of chlorhexidine at St George Hospital in 2010. The […]
Competition
Competition can help drive improvement up to a point, after which it may perpetuate unnecessary harm. We’re nurtured in competitive environments from an early age. Throughout school we’re constantly being graded and ranked. We are conditioned to compete. When a peer makes a mistake they may be perceived as lesser […]
Ban Indistinct Chlorhexidine – Update
Indistinct chlorhexidine (circled) still exists in many hospitals despite almost 500 front line staff signing a petition to have it banned. This completely unnecessary hazard has lead to the death and morbidity of many patients throughout the world (see here). This issue highlights the failure of hierarchical top down […]
Facing up to ‘Command & Control’
Team Briefings
Human In The Team
Liposuction – Do You Consent?
There is no medical benefit to liposuction and significant risk of harm. The death rate from liposuction, 1 in 5000, is 20 times greater than that of other surgical procedures. Within the past 10 years there have been at least 17 deaths from liposuction within Los Angeles alone. All of them female: […]
Reduce Oxygen – Air Flow Meter Mix Up
