We asked numerous doctors and nurses if they’d heard of IRIS – none had. We couldn’t access IRIS through the NSW Health Intranet. IRIS is hidden, disconnected, and consequently ineffective. This is unfortunate given it is vital for patient safety. IRIS stands for Incident Reporting & Investigation System – the Therapeutic and Goods Administration (TGA) rely on it to review medical equipment. The TGA are the … Continue reading Have you ever heard of IRIS?
In 2010 a tragic event where chlorhexidine was mistaken for saline left Grace Wang paralysed (see here). A formal investigation of the incident made this recommendation: However indistinct preparations of chlorhexidine still exist in many hospitals leaving patients at unnecessary risk. Attempts to have it banned through current health care frameworks have been unsuccessful. Numerous similar cases of inadvertent chlorhexidine injection have occurred (see here) leading … Continue reading Ban Indistinct Pourable Chlorhexidine