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).
Government Saftey Alert March 2019
- enFlow® IV fluid and blood warmer - risk of unsafe levels of aluminium leaching from the device (MDA/2019/015) - Cartridges with an aluminium warming plate in the fluid pathway can lead to an IV infusion containing aluminium above currently recommended safe levels.
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.
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 firstname.lastname@example.org.
SAFETY MATTERS: Local Incident Lessons