Together we’ll create the best environment for patient care
‘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 […]
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 […]
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 […]
Please click here to see a great review article on the history of laryngoscopy.
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 […]
The delivery of paracetamol from a glass vial allows air to enter the intravenous giving set risking venous air embolus. Paracetamol is already presented in bags which don’t entrain air and is used in this form without issue in many hospitals. The distraction afforded through keeping a watchful eye on […]
Australian Hospital Staff – please complete this very brief (less than 1 minute) survey to assess mobile phone reception (click here). The results will be used to help drive improved communication systems in the interest of patient safety. Perhaps the greatest impediment to patient safety is the inability for front […]
The Vortex Approach is designed to be used during the high-stakes, time critical situation of an evolving airway emergency. It is intended to help clinical teams perform under pressure by providing a simple, consistent template that can be taught to all clinicians involved in advanced airway management, irrespective of critical […]
In Australia, 2016 was marred with the events which occurred at Bankstown Hospital (see here). More deaths have occurred because of accidental hospital gas pipeline cross-overs. (To read about cases click on each image box below): In Australia, 2016 was marred with the events which occurred at Bankstown Hospital (see […]
The Between the Flags (BTF) system is a ‘safety net’ for patients who are cared for in NSW public hospitals and health care facilities. It is designed to protect these patients from deteriorating unnoticed and to ensure they receive appropriate care if they do. The BTF program addresses the Australian […]