Join the ‘Latent Error Of The Week Challenge’ #LEOTWC
Thanks for all your responses so far – we promise to post all of them in time. Here is a reminder of the rules:
Latent Error = Hole in the Piece of Cheese, that piece of equipment or system hazard that is sat waiting to contribute to an adverse event.
Scores – maximum 31, made up from
A. How obscure & well described the latent error is /10
B. How severe the predicted adverse event could be /10
C. How effective your measures to remove it are /11 (this is where the money is – there’s no point in reporting a latent error if we don’t put something effective in place to remove it)
Anonymous (no patient / staff / institution names please)
It doesn’t sit well with us either but we’re desperate to get rid of these latent errors (think Sixth Sense – we see latent errors and they’re everywhere). Please help.
Forced Air Warmers
Burns from hosing of forced air warmers is a severe issue – the information and learning from these incidents is often lost in time and place. The picture below always reinforces never to hose directly under blankets, however not everyone will see it. Also hospitals keep the same forced air warmer but may purchase the warming blankets from other (cheaper) manufacturers and the hose may disconnect leading to patient burns. This response from APSF was probably the best available at the time – however now we have a much more effective and sustainable solution – getting rid of them where possible and replacing with activated warming blankets.
A. 7/10 – nice in your face pic, grabbed off internet, wish it was in colour, very glad we weren’t there at the time (schadenfreude)
B. 7/10 definite potential to maim
C. 5/11 trial of active warming blankets at a large tertiary hospital and are seeing them used elsewhere. Trying in vain to contact heads of procurement at some private hospitals (must try harder)
19/31 (a rosy tinted spectacle outlook on this one)