Hospital Gas Pipeline Mix Up Causes More Deaths

More deaths have occurred because of accidental hospital gas pipeline cross-overs. (To read about cases see here).   In Australia, 2016 was marred with the events which occurred at Bankstown Hospital (see here). NSW Health should be commended on the publication of their recommendations following the tragedy. It is useful to identify those involved, the procedures used and assess why errors were made. However consider for … Continue reading Hospital Gas Pipeline Mix Up Causes More Deaths

Petition to Ban Indistinct Chlorhexidine

Hundreds of patients have been injured and killed because of this completely unnecessary hazard. Pink chlorhexidine antiseptic (centre in image) is indistinct and easily mistaken for other colourless solutions. It’s been accidentally injected into patients spines causing paralysis, legs leading to amputation, and arteries supplying the brain causing agonising death. There’s hundreds of cases (see here). Red chlorhexidine (on right in image) is exactly the … Continue reading Petition to Ban Indistinct Chlorhexidine

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Obstacles to Patient Safety

Everyone who belongs in healthcare passionately wants the best for patients. Medical error, however, persists as the third greatest cause of death. We have tremendous opportunity to improve. So what are the obstacles to patient safety? Despite appearing simple, removing unnecessary hazards within healthcare frameworks is extremely difficult. This ongoing series of posts uses specific hazards to demonstrate the obstacles to patient safety. We’ll persist … Continue reading Obstacles to Patient Safety

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Central Line Air Emboli: one death every day?

Central lines are essential for the care of many patients. Unfortunately worldwide data indicate around one patient is dying every day from avoidable central line related air emboli. We would appreciate your feedback on the numerous case series and reports presented below. (Please click on any links in red). Many cases occur because of accidental line disconnections (this problem can be engineered out – see here). … Continue reading Central Line Air Emboli: one death every day?

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What’s in the pipeline? Will we learn?

When adverse events occur our first instinct is to discover who or what is to blame. Staff may be remonstrated and potentially removed, in itself warning others not to make similar mistakes. Governing authorities may review related policies to prevent such errors in the future. This has been the response to the Bankstown gas pipeline tragedy (see here). Taken in isolation the recommendations made through the … Continue reading What’s in the pipeline? Will we learn?

Vascular Access Decision Tree

At least 50% of central lines are unnecessary. Routine peripheral cannulae (PIVC) replacement is unnecessary. 6 central line air emboli deaths were reported in NSW in the last 2 years. The real incidence is likely much greater, and they’re happening throughout the world. Clusters have also been recognised in Pennsylvania US. All cases are avoidable. Air emboli represent a fraction of central line adverse events. … Continue reading Vascular Access Decision Tree

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Why can’t staff just be more careful?

This sign may represent current health care safety strategy: ‘When faced with a human error problem you may be tempted to ask ‘Why didn’t they watch out better?’ How could they not have noticed?’ You think you can solve your human error problem by telling people to be more careful, by reprimanding the miscreants, by issuing a new rule or procedure. They are all expressions … Continue reading Why can’t staff just be more careful?

RCA states: ‘Antiseptics should be distinctively coloured’

A Root Cause Analysis report leaked to the Sydney Morning Herald requested: ‘antiseptics should be distinctively coloured’ but they aren’t and patients are left at unnecessary risk. Why? Help us ban pourable pink chlorhexidine by clicking here and signing the petition. Front line staff need to be empowered to remove obvious patient safety hazards from their workplace. Read more here… Continue reading RCA states: ‘Antiseptics should be distinctively coloured’

Cure discovered in all of us

A cure to one of hospitals biggest killers is within all of us. Within hospitals, medical error is the third greatest cause of death. If we accept this, transparently identify hazards, and are enabled to introduce effective solutions we have the cure. Currently reporting systems are used where adverse events are fed into layer upon layer of administration. This rarely leads to effective change. Healthcare … Continue reading Cure discovered in all of us

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The Healthcare Safety Machine Needs Fixing

The healthcare safety machine needs fixing. Is there anyone out there who can help? Medical errors are the third greatest cause of death in hospitals. We know this. ‘The real problem isn’t how to stop bad doctors from harming, even killing, their patients. It’s how to prevent good doctors from doing so.’ Atul Gawande Terry Fairbanks is an expert on system safety. Watch his video here. … Continue reading The Healthcare Safety Machine Needs Fixing