Together we’ll create the best environment for patient care
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 […]
It goes without saying that a basic principle in a high risk industry like healthcare is ensuring all staff are properly trained to perform their tasks, and demonstrate regularly that they can maintain their skills. It should be a given. But surprisingly, it’s not. At first glance, you might find […]
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 […]
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 […]
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 […]
If patient safety is to improve healthcare needs to change. The historical top down approach which has hindered improvement requires a transition into one where decisions are driven from the front line. Those corporations who’ve introduced front line driven frameworks (e.g. Toyota Production System – see here) provide the highest quality in […]
Front line work environments are full of unnecessary distractions detracting focus from the task at hand. They come in many forms from a noisy vacuum cleaner disrupting a patient consult, to a poorly designed electronic medical recording system. Dr Gordon Caldwell has presented much work specifically looking at how distraction […]
If you went skydiving, would you first ask for scientific evidence from a randomized trial that a properly functioning parachute prevents injury before you’d consider using one during your freefall? Probably not. In fact, no such study exists. Of course, some people without a parachute have survived a freefall from […]
The patient declined rapidly, the arrest call went out, staff rushed into the operating room. Some helped obtain intravenous access, others drew up adrenaline, and the arrest trolley was brought in. As the patient’s cardiac output disappeared the anaesthetist asked for someone to commence cardiac compressions then turned to put […]
Even when there’s overall agreement a proposed intervention will improve patient safety there’s one word which can stop its implementation. This word is most often used by those in authority – in accepting the intervention they’ll need to accept the previous way they presided over wasn’t as good. The ‘C’ […]