Safety and quality update: August 2022

09 August 2022

New this month: safety alert update on epidural kit supply disruption, plus others; PBS changes for hydromorphone oral solution; updated COVID-19 surgery guideline; call for medication error reports; Opioid CCS; and more.

Safety alerts

  • Management of potential supply disruption to epidural kits (new update)
  • Defect: Aisys CS2/Avance CS2/Avance CS2 Pro Anaesthesia Systems, switched O2/air pressure reading
  • Safer Care Victoria Alert: Xylocaine 2% with Epinephrine batch #9949864 (update)
  • Product Defect Alert: Pressure Plates used in Level 1 Fast Fluid Flow Fluid Warmers
  • Australian Recall: Medtronic Covidien Shiley Hi/Low-Contour Oral/Nasal Tracheal Tubes Cuffed

See all Safety alerts

Changes to Pharmaceutical Benefits Scheme Australia listing of hydromorphone oral solution

Changes to dispensing volumes for hydromorphone oral solution on 1 August 2022 will assist good opioid stewardship in prescribing for children and adolescents.

Read more

Updated guideline on surgical patient safety and COVID-19

Read our updated guideline on surgical patient safety for SARS-CoV-2 (COVID-19) infection and vaccination, with a minor update on intraoperative vaccination.

Read guideline

Call for reports: medication errors with muscle relaxants or ampoule similarity

ANZCA and ANZTADC are calling for anaesthetists to report all medication errors and near misses to webAIRS, especially those involving muscle relaxants or ampoule similarity.

We have an opportunity to present data on the prevalence of these errors to the Therapeutic Goods Administration (TGA) and Medsafe New Zealand in October 2022, and we need your contributions.

The TGA is considering improvements to the labelling of ampoules containing neuromuscular blocking drugs (NMBD). This is a great opportunity to influence regulation to reduce the rate of errors and improve patient safety.

Are you contributing to incident reporting and quality improvement in anaesthesia? Visit the webAIRS website to register or email for more information.

Visit webAIRS

ANZCA and FPM endorse Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard

ANZCA and FPM are pleased to announce our endorsement of the Australian Commission in Safety and Quality in Healthcare’s Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard. Although this standard was released in April 2022, ANZCA and FPM delayed endorsement until we could complete the review of our own PS41(G) Position statement on acute pain management, to ensure alignment of the documents.

The Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard describes the key components of care that patients can expect when they are prescribed opioid analgesics for acute pain in acute care settings.

Read the standard

Preparing for statutory duty of candour in Victoria

Amendments to the Health Services Act 1988 (Vic) introduces new legal obligations that will require relevant Victorian health service entities to apologise to patients and their families or carers when the patient has suffered a serious adverse patient safety event. The reforms also introduce new protections for serious adverse patient safety reviews.

To help clinicians prepare, there will be three webinars for workers from different types of health service, between 25 August and 1 September. There will also be a launch event aimed at health service CEOs, board members and other leaders on 18 August.

Read more

Joint statement by the Medical Board of Australia and Ahpra on building a positive culture in medicine, and social media use

Poor culture is associated with poor patient outcomes, which places the issue firmly within the scope of regulators. The Medical Board of Australia and Ahpra have issued a joint statement on the importance of a culture of respectful communication in medicine. It includes links to three recent tribunal findings around practitioners’ use of social media.

Read statement

Beard wrapping can improve safety for health staff unable to shave

The NSW Clinical Excellence Commission's Infection Prevention and Control team have worked with doctors from the Sikh community to assess the efficacy of under-mask beard covers to achieve an adequate seal with tight-fitting P2/N95 respirators and fit testing, resulting in an article published in the Journal of Hospital Infection.

Read more

Clinical Communiqué 20th anniversary anthology edition

The June 2022 edition of the Clinical Communiqué is a milestone that marks 20 years of this publication, previously known as the Coronial Communiqué. The Communiqué aims to improve awareness of clinicians and those in leadership of adverse events resulting from systems failures, and then to apply these lessons to their own institutions. This issue takes the form of an anthology of patient safety expert commentaries, from clinicians, researchers, lawyers and coroners.

Read the issue

Last updated 13:16 12.08.2022