Medical error has been reported as the third greatest cause of death. Front line staff are surrounded by numerous unnecessary hazards they feel powerless to remove.
We believe patient safety will improve through the completion of hundreds of specific projects.
The progress of each project will be made transparent. Feel free to lend your support and input. Please click on each link in red for more information:
‘Valved’ IV fluid bags – offer a significant safety feature over valveless fluid bags. They’re also cheaper, yet the majority of hospitals still use valveless fluid bags.
Central Line Air Emboli – at least 1 patient dies every day from central line related air emboli. All cases are avoidable. We present effective solutions to this problem.
Hospital Gas Pipeline Mix Up – we present many cases of gas pipeline mix up over time and throughout the world. We note that despite our best efforts (policy review, education etc) gas pipeline errors will persist – to err is human. We provide a mechanism to capture them when they do occur which will prevent them causing patient harm.
Burning dental drills – most electricsl dental drills will heat up as their bearings begin to wear with time. Thousands of patients have suffered permanent facial scarring from burns because of this. Dental drills which don’t heat up already exist and should be made mandatory.
Stop the routine replacement of peripheral cannulae – despite the best evidence not supporting the practice of routine cannula replacement this practice persists in many institutions. Changing to a replacement as required policy would have major beneficial impact on front line work efficiency.
Ban indistinct chlorhexidine – Indistinct pourable versions of chlorhexidine have been injected into hundreds of patients causing deaths and significant morbidity. There is no need for these indistinct versions in our hospitals – many institutions use vividly coloured versions of chlorhexidine without issue. Despite over a petition 400 signatures from front line staff to ban it indistinct chlorhexidine still persists in our hospitals. This is an embarrassing reflection of how inneffective healthcare safety frameworks can be.
Recall old Draeger APL valves – Draeger APL valves from pre 2010 can become trapped open. This has lead to numerous catastrophic inability to ventilate events. The valves should be recalled and replaced with the newer version.
Paracetamol Bags not Vials – Intravenous Paracetamol presented in bags confers a safety advantage over that presented in vials.
Between the flags patient observation charting and response – this fantastic system approach to capturing patients before they deteriorate was developed by the Clinical Excellence Commission, part of NSW Health
Medical device mis-connections – numerous patients have died because of accidental line mis-connections. We provide a link to the FDA resource focusing on this issue. We could effectively engineer this problem out.
EZDrugID – different drugs are often presented in almost indistinguishable vials. This has led to numerous drug errors. We need an international standard for the appearance of drugs.
Suxamethonium prefilled syringes – represent a cost saving, environmentally friendly patient safety measure. Bring it on.
Video & Direct laryngoscopes – Portable laryngoscopes which offer both direct and video views offer safety advantages over other laryngoscopes. They should be available for use first line for every intubation.
Sugammadex Availability – A box of Sugammadex should be immediately available in every operating theatre to confer optimum patient safety.
Mobile phone reception – many front line staff note lack of reliable communication networks as perhaps the greatest impediment to patient safety. Archaic and unreliable paging systems slow down vital communication between staff – ultimately patients suffer. If hospitals had guaranteed mobile reception the opportunities for improvement are huge.
Gas analysers – broader use of gas analysers will save lives
Generic consent – cosmetic surgery is financially driven. Is it wise to trust those who profit most from these procedures to provide informed consent.? Perhaps a better way forward requires a standardised generic consent process where we can assess if the information has been clearly understood by clients presenting for these procedures.
Oxygen Cylinders – poor design of some newer oxygen cylinders renders it likely that staff will accidentally forget to turn them on – they appear to be turned on when they are actually turned off. Several patients have already dead because of this. We need to replace them for patient safety.
Standardisation of the Hospital Emergency Number – Given staff work across numerous different hospitals it is extremely difficult for them to remember a different number at each hospital. In 2006 the British NHS standardised the hospital Emergency Number at ‘2222’ – a survey of hospital noted 27 different numbers in use prior to this. From an ongoing survey in Australia where we have collated data from almost a third of hospitals the number of different Hospital Emergency Numbers stands at 48.
Anaesthetic Circuit Filters – In 2002 police operation Orcadion was set up to investigate the deaths of patients from blocked Anaesthetic circuits. In some instances cases occurred because of caps accidentally falling off filters blocking the circuits. There is no need for these caps to come off – tethered caps which don’t come off already exist and are much safer. We aim to remove all Anaesthetic filters with removable caps from the front line.
#TheatreCapChallenge – visible staff indentification on their person by name & role in theatre will lead to improved communication, team work and patient outcomes.
#hellomynameis – Chris Pointon is spreading the message throughout healthcare worldwide. We are looking into name and role embroidered scrub tops and shirts for those staff who work in emergency departments and on the wards.
Defibrillators – the design of defibrillator cardioverters lends to fatal mistakes in how staff use them. We will look at and promote how they can be redesigned to minimise mistakes.
Continuous monitoring of postoperative patients – morbidity and mortality from postoperative respiratory depression is avoidable. We are trialling continuous patient monitoring postoperatively.
Standardised giving sets & intravenous lines – We are reviewing the benefit of minimum standards for the design of intravenous lines.
Diathermy burns – thousands of patients have been unnecessarily injured from diathermy. We will present and promote effective ways to minimise this.
Video and audio recording of procedures – the video and review of medical and surgical procedures could provide major advantages to both patients and healthcare staff. There are understandable concerns about privacy of information. We hope to explore the best ways to overcome this.
Dental sedation – thousands of patients have died unnecessarily from sedation in dental chairs. The practice of ‘sleep dentistry’ is increasingly marketed. We will review how this service might be better regulated.
Anaesthetic assistants – Within Australia anaesthetic technicians have no registering body and in many states have scant frameworks for education and support. We look to how this might be improved.
Automated/Bar code cold chain blood product storage – The ‘cold chain’ is an essential process to ensure blood products aren’t left unrefrigerated for too long. Introduced systems in many institutions to ensure the cold chain process is complied with are complicated and difficult to follow. This has lead to increased blood product wastage. We will look at other automated systems to improve work flow.
Standardised giving & pump sets – Intravenous giving sets come in a myriad of different shapes and sizes. Each may have their own hazards (see here). Perhaps it’s time to collaboratively introduce minimum standards for these devices which removes these hazards. There is no need for intravenous administration sets to open to air – certainly something we can look at enforcing.
Please let us know if you’re aware of any other patient safety projects or are interested in commencing a new one – we will add it to the list.
With your help and your reports there are many more projects to come. Together we can fix healthcare safety.