Safety and Quality Updates: March 2023

17 March 2023

HFNO safety alert, risk of injury cause by shattered glass ampoule to staff member, WebAIRS incident report of pneumothorax injury suffered by patient.

New Safety Alerts

Glass ampoule injury

A safety hazard has occurred in which a shattered glass ampoule has caused significant injury to a staff member. This defective ampoule was concluded to be an isolated case and is not indicative of a widespread fault within the manufactured batch.

Such accidents not only represent a hazard to staff but also to patients due to delays caused by retrieving a replacement ampoule and then administering the contained drug. Medical personnel are advised to take care when handling similar medical equipment.

WebAIRS incident: Pneumothorax

WebAIRS has recently received an incident of a patient sustaining a pneumothorax following hepatobiliary surgery. Following the prompt communication by the surgeons to the anaesthetic team, it was repaired intra-operatively and no further issues transpired.

The reporter noted that this is a recognised problem with complicated or difficult upper abdominal surgery and asked whether we should be performing a routine lung ultrasound in ‘at risk’ patients to improve their outcomes. ANZTADC welcomes additional feedback on the topic or the submission of other similar incident reports.

Join webAIRS to report any anaesthetic incidents.

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Last updated 13:56 17.03.2023