The Faculty of Intensive Care Medicine Bulletin: Safety incidents in critical care newsletters

Summary

Through a data sharing agreement, the Faculty of Intensive Care Medicine can access a record of incidents reported to the National Reporting and Learning System (NRLS). Available information is limited and from a single source; all that is know about these incidents is presented in this report. The safety bulletin aims to highlight incidents that are rare or important, and those where the risk is perhaps something we just accept in our usual practice. It is hoped that the reader will approach these incidents by asking whether they could occur in their own practice or on their unit. If so, is there anything that can be done to reduce the risk?

Content

February 2024

• Needlestick injuries
• A missed prescription
• Inevitable harm?
• Air emboli
• The patient, the machine and everything inbetween
• Harm from a safety measure
• Unknown patients
• Retained foreign body
• Serotonin syndrome

October 2023

• Central line misplacement.
• Missing vital information.
• Can risk be avoided?
• Vasopressors outside the ICU.
• Mediastinal drains.
• Failure to recognise

July 2023

• Imaging
• Central venous access
• Nasogastric trauma
• SGLT-2 inhibitor associated diabetic ketoacidosis
• Chest drain clamps
• Where's the drain?