What were the recommendations in response to the St George Epidural incident?

A Root Cause Analysis performed in response to the epidural tragedy at St George Hospital recommended:

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but they aren’t and patients are left at unnecessary risk.

Please help ban indistinct pourable chlorhexidine – click here and sign the petition.

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There were numerous holes in the ‘Swiss Cheese Model’ that led to the epidural case at St George Hospital in 2010.

Each institution has developed their own response to minimise the likelihood of it happening again – each response has merit, adhering to them is wise, however some responses may lead to their own issues (e.g. using an inferior antiseptic). Anaesthetists are rarely confined to one institution, they may find it difficult to adhere to several different approaches to the same process. In turn they might develop an amalgamation of approaches that could introduce its own risks.

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 From: Responsiveness to the Chlorhexidine Epidural Tragedy – A Mental Block

‘Catastrophic errors in medicine are frequently the result of multiple errors. In the two Sydney cases and in the Achilles tendon case, decolourised solutions of chlorhexidine in alcohol made recognition of the mistake more difficult.’

The Root Cause Analysis of the St George event made a recommendation that darker coloured chlorhexidine solutions should be used. This recommendation failed to appear in an alert sent out by NSW Health after the event we are unsure why. Many front line staff failed to receive any alert at all. The communication networks for distributing alerts are poor, and alerts are limited in time and place.

Alerts, education and policies have limited effect in creating system safety (see The Hierarchy of Intervention Effectiveness). Teaching is unfortunately limited in time and place – there are anaesthetists who had never heard the historical cases of paraplegia from suspected splash contamination of spinal needles until after the case at St George. (see The sting in the tail: antiseptics and the neuraxis revisited)

Through all of this, almost colourless, pourable solutions of chlorhexidine still exist in many hospitals.  The biggest hole in the ‘Swiss Cheese’ lives on.

Please help ban indistinct pourable chlorhexidine – click here and sign the petition.