Learning from Patient Safety Incidents

It is estimated that 1:10 patients in health care sustain harm that is potentially avoidable and which often highlight system errors that were not appreciated.  Investigation results in the identification of these system errors and the generation of solutions to prevent future incidents. Sharing and implementing these lessons improves patient safety.

 

National Patient Safety Alerts relevant to intensive care

National alerts are produced in response to analysis of centrally reported patient safety incidents. Details of all alerts may be found on the Central Alerting System website (https://www.cas.mhra.gov.uk/Home.aspx).

 

National Patient Safety Alert: November 2019

Depleted batteries in intraosseous injectors November 2019

The Faculty have recieved news of the following national patient safety alert.

'The intraosseous (IO) route (that is, through the bone marrow) is used to access the venous system when intravenous access is not possible to administer medicines or fluids, often in emergency situations, including cardiopulmonary resuscitation. IO access is most commonly achieved using a battery-powered injector.

As the battery is sealed within the device and cannot be recharged or replaced, the first sign a battery may be depleted is in some circumstances when it does not work.

The alert asks providers to replace any battery-powered IO devices that do not have a battery power indicator light with ones with a display that shows how much power is remaining. Where IO devices with a battery power indicator are used, providers are asked to take steps to regularly check these devices to ensure sufficient battery power remains so the devices are always ready and available.'

We reccommend clicking the link above to read about the depleted batteries in further detail.


Government Saftey Alert March 2019

Regulation 28 Reports to Prevent Future Deaths

The Faculty receives reports from the Chief Cororoner where it is believed action should be taken to prevent future deaths. Those relevent to Intensive Care Medicine will be published here. 

Regulation 28 Report: Pathway for urgent neurosurgical procedures (February 2017)

Regulation 28 Report: Air embolism (April 2018)

Lessons from adverse incidents

Lessons from local incidents may not be shared widely and to improve wider patient safety, the Professional Affairs and Safety (PAS) Committee of the Faculty has developed this forum to allow lessons from local investigations into adverse incidents to be disseminated to the intensive care community.

We welcome you to share important safety lessons that have occurred in your own departments that may have general relevance. Please use the form below (or your local form if you would prefer) to submit an anonymised summary of the incident, the learning arising and any changes that have been implemented to prevent future a reoccurrence. The forms should be sent to contact@ficm.ac.uk. 

Local Patient Safety Incident Form


SAFETY MATTERS: Local Incident Lessons

Stroke following central venous line

Accidental phenytoin overdose

Manual bolus dose of insulin

Incorrect connection of epidural infusion 

Retained foreign object post procedure

Vascath Stylet Fault