Safety and quality update: September 2022
13 September 2022
New this month: safety alerts; ACSQHC Low back pain clinical care standard; Victorian liposuction guideline; webAIRS events NZ; sepsis stocktake and other NZ news; and more.
- Compatibility of intravenous access connectors with pre-filled syringes – especially glass
- Defect: Gentec 286MB 25LY2A click-style oxygen regulators – SIS seal collar is removable
- Recall: Cook Medical Fixed Core & Roadrunner Hydrophilic Wire Guides – compromised sterility
- AU recall: Philips BiPAP A40 – non-conforming materials could cause off-gassing or device failure
- AU recall: ITL Australia catheter kit – compromised sterility of specific models/lots
- New Zealand recall: CareSens KetoSens Test Strip – specific batch returns false readings
See all Safety alerts
ACSQHC Low back pain clinical care standard
The Australian Commission for Safety and Quality in Healthcare (ACSQHC) has launched its Low Back Pain Clinical Care Standard, which aims to improve the early assessment, management, review and appropriate referral of patients with this common health condition. The standard includes:
- Eight quality statements describing the care that should be provided.
- A set of indicators to support monitoring and quality improvement.
The Faculty of Pain Medicine (FPM) contributed to the development of this standard, and has provided formal endorsement. A video of the launch event on 1 September 2022 is available to view, as are presentation slides and a communications kit.
View and download
Guideline for providers of liposuction in Victoria
The Department of Health, Victoria, has released Guideline for providers of liposuction: A best practice guideline for clinicians and providers of liposuction in Victoria. This guideline was developed by an expert working group including ANZCA fellows, and has been endorsed by ANZCA.
Liposuction is a service that is regulated in Victoria and can only be performed in a facility registered with the Department of Health. The guideline applies to:
- All liposuction procedures over 200mls, which are required in Victoria to be performed in a registered facility.
- All facilities and practitioners providing liposuction.
- All forms of liposuction, irrespective of the method used, dry, tumescent, super-wet etc.
- Liposuction regardless of the method of anaesthesia.
- Liposuction performed in conjunction with other procedures.
It is noted that changes to cosmetic surgery regulation are currently contemplated at the Australian Government level. The guideline will receive ongoing updates as circumstances change.
WebAIRS at the Combined Scientific Congress NZSA & ASA – Wellington New Zealand 21 – 24 October 2022
A reminder that two webAIRS events will be held at the Combined Scientific Congress of the New Zealand Society of Anaesthetists (NZSA) and the Australian Society of Anaesthetists (ASA) in Wellington, New Zealand.
- Case analysis workshop, hosted by ANZTADC, Friday 21 October,1.30 – 3.00pm (ANZCA CPD eligible)
This participatory workshop will utilise case scenarios based on de-identified cases reported to webAIRS. You will also learn how to report incidents into webAIRS, which incidents to report, using webAIRS at your local morbidity and mortality meetings, and about the webAIRS case analysis and discussion process.
- Learning from adverse events, Sunday 23 October, 3.30 – 5.00pm
Close to 10,000! Incident reporting in Australia & New Zealand
Dr Yasmin Endlich
Medication errors reported to webAIRS: unusual pitfalls and some strategies to avoid them
Dr Martin Culwick
Advisory Notices for Anaesthetists: A webAIRS safety initiative inspired by the airlines
Dr Russell Rarity
Visit the webAIRS website to register to report anaesthetic incidents.
Register for CSC
Sepsis, medicines at transitions of care, consumer engagement – news from Healthcare Quality and Safety Commission Aotearoa New Zealand
Blood Matters Victoria report: use of electronic medical records for blood management and transfusion
Blood Matters has released a survey report illustrating current design and implementation of blood management and transfusion practice within electronic medical records (EMRs), and the effect on patient safety and blood use. Findings may assist and inform sites yet to implement an EMR, and help identify areas for optimisation for those with an EMR.
Health services are asked to circulate and review the report, noting current compliance and gaps in practice.
Reminder: call for reports – medication errors with muscle relaxants or ampoule similarity
A reminder that 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.
Value-Based Health Care Delivery: An Intensive Seminar, 9-13 January 2023, USA
The Value-Based Health Care Intensive Seminar is a five day, full-time course offered in-person at Harvard Business School, and taught by a team of faculty and health care industry leaders. Through a mix of case study discussions, case protagonist appearances and concept lectures, course participants will develop a thorough understanding of value-based health care principles, including an introduction to outcomes measurement and time-driven activity-based costing. International applicants are welcome, noting that in-person attendance is required. Tuition is free; entry is via application and is competitive. Course dates are 9-13 January 2023. Applications close Friday 28 October 2022, 11.59pm USA Eastern Time.
This item appears in Safety and quality update on the recommendation of a senior ANZCA fellow who has attended.