Progress Update

There are thousands of unnecessary hazards in our hospitals. We have selected a handful and will work tirelessly in the interest of patient safety until effective solutions are implemented.

This progress report will be updated regularly: 28.9.16

Indistinct chlorhexidine
– numerous cases of death and injury have been attributed to indistinct chlorhexidine (see here). Suitable alternative preparations of chlorhexidine exist and are already used without problem in many hospitals.
– over 270 people have signed petition requesting ban
– TGA as yet have refused to ban
– numerous additional cases discovered in seperate reporting databases
– Sydney Local Health District removed from public hospitals (with thanks).
– Perrigo (one of the manufacturers) have changed the colour of their pink chlorhexidine to make it more distinct (see here)
– Request sent to TGA, ANZCA, AHQSC to enforce ban.

Draeger APL valves
– old Draeger APL valves can be trapped open while they appear closed – patients cannot be ventilated and are left at unnecessary risk. There’s been numerous reports of adverse events from the issue (see here). Draeger have redesigned their APL valves with a bevel to overcome this issue – they could replace their old valves with their newer version.
– Draeger have refused to recall. Have refused to contact users of older valves or provide heir contact details (apparently 78 old valves are left in Australia)
– TGA have so far refused to recall and have refused to send industry alert to users
– ANZCA has sent an alert (see here)

Valved IV fluid bags
– non-valved IV fluid bags entrain air when disconnected. If these bags are re-spiked the air may enter patient’s blood vessels. Patients have died as a result (see here)
– valved IV-fluid bags already exist and are used in many hospitals without issue.
– we ask that non-valved IV fluid bags be replaced by valved ones
– TGA, AHQSC, ANZCA, CEC are aware. We await their further response.

Central Lines with moulded valves
– numerous patient deaths have occurred when central lines have accidentally been left open to air (see here)
– central lines with moulded valves are used in several hospitals outside Australia. They reduce the risk of accidentally being left open to air.
– CEC sent out a request to industry August 2015
– an application for registration was provided to TGA in Nov 2015
– TGA registered use of equipment October 2016

Support the Implementation of Gas Analysers in Areas of Resuscitation #SIGMAR16
– Gas analysis monitors have been present on anaesthetic machines for years
– broader implementation of these monitors in other areas of resuscitation will save lives (see here) – their presence on neonatal resuscitation trolleys will have prevented the Bankstown tragedies.
– ANZCA, AHQSC, CEC aware. We await their further response.

Access to error report database
– despite entering incident reports front line staff are unable to access incident report databases
– access to these databases is limited to the governing bodies
– numerous different error databases exist in Australia. They do not communicate with one another and are not transparent. Front line staff are unable to learn from the valuable information contained within them.
– solutions to reported incidents often have limited if any effect in preventing future adverse events: this is the top down approach which heavily relies on education and policies (see here)
– in NSW we are comunicating with governing bodies CEC, NSW Health to allow front line staff access to the IIMS database. We will keep you updated of progress.