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?
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