Page 11 - ANZCP GAZETTE DECEMBER 2023

Permission to print: Category
Category Incident type
Incident type Duration of incident:
Duration of incident: Description:
Description:
Yes
Drug / Medication
Drug / Medication Good Catch Near Miss
Good Catch Near Miss minutes
What could we do better Whatcouldwedobetter
Preventive actions Preventive actions
Type of incident:
Type of incident: Hospital incident filed:
Hospital incident filed: Ext Authority Advised
Ext Authority Advised Discussed with team:
Discussed with team: Knowledge issue
Knowledge issue Protocol issue
Protocol issue Skill issue
Skill issue Team Issue
Team Issue
Patient outcome variance f
Patient outcome variance f
a decision was made to change the circuit so the patient would not have a reaction. There was some confusion due to the hand-written allergy notes and no notes electronically.
TAhtetirmeewoaustsoImcoeulcdohnafuvseiocnladriufiedtowtihtehhthaenda-nwareisttehnetaislltewrghyicnhoatenstiabniodtincownaostgeisvelne.ctronically. At time out I could have clarified with the anaesthetist which antibiotic was given.
Confirm OK for cephazolin (standard antibiotic for our institution) with CanoanefiartmheOsKiafporiocer ptohazdodling(satnantidbaiortdicatnotitbhioetpicrifmoreour institution) with
anaeathesia prior to adding antibiotic to the prime Management
Management No
No No
No No
No No
No No
No No
No Yes
Yes Nil
Nil
PIRS-2 REPORT
Tim Wilcox CCP, Life Member ANZCP - PIRS-2 Editor
There have been only a few submissions to PIRS since the last Gazette publication, interestingly the majority from outside of Australia and New Zealand despite continued anecdotal reports of near miss and no harm good catch incidents. The value of these workarounds that save bad outcomes are valuable and PIRS encourages centres to share these experiences.
Formerly PIRS, the Perfusion Incident Reporting System was established by the Australia and New Zealand College of Perfusionists in 2004 to document incidents and accidents and share solutions and preventive actions.
The change from Incident to Improvement is in line with the shift to Safety-II concept thinking. The primary aim of PIRS-2 is to build resilience into perfusion practice by capturing what went well (the “Good Catch“) in near miss and no harm incidents, as
2023 Drug / Medication (Prime)
well as learning from harmful incidents. We encourage reporting the frequent workarounds that averted more serious outcomes that are very often subject to the fix and forget phenomenon.
PIRS-2 is a voluntary system, Confidentiality is assured by de- identification and anonymity of reports within 72 hours of submission. The 72 hour window is to allow questions to be asked of the reporter where detail of the event is unclear to the PIRS-2 editor.
De-identified PIRS-2 reports details may only be published on the PIRS-2 pages of the ANZCP website or in the ANZCP Gazette if permission to publish is given in the report form.
PIRS-2 data will not be passed to any third party or regulatory body including the ANZCP or Registration authorities. Forwarding any information is the responsibility of the reporter.
©ANZCP 2020. All Rights Reserved.
2023 Drug / Medication (Prime) Permission to print: Yes
minutes
I was sitting in theatre with the AV loop divided, ready to start cannulation. The patient had a
Irewaacstisointttinogsoinmthetehaitnrge twhiatthmthaedAe Vthleooppredsisvuidresd,arnedahdey atrot srtaatret dcaronpnutola2ti0ona.nTdhMe ApaPtSieintohtahdea r3e0asc.tTiohnistwoassotmreattheindgbtyhantameastdheetshiaeapnrdesrseusroelsveadndinhaebaorturta2temdinrouptetso. 2T0heanadnaMesAtPhSetiinstomthadee 3a0cso.mThmisewntaasbtoreuatttehdebpyaatineanetsbtehiensgiaaallnedrgriecstolvaeldotinofatbhoiuntgs2. mI hinaudtcehse. cTkhedatnhaeepstahteietnistnmoatedse aoncloinmemanendthabdosuetetnhenopawtiaerntinbgeianbgoaultledrrguicgtaollearlgoiteos,fhthoiwngesv.eIrhinadthcehepchkyesdictahlepaptaietinetnntontoetses othnelirneewaansdahlaisdtsoefeanllenrogwieasrhnaingd-awbroituttednr.uIgdiadllenrogtieses,ehtohwiselivset.rWinetheadphdyosniceaal ptaimtienotuntoatneds it twhaesrecownafisrma leisdttohfaatlalenrtgibieiosthicasnhda-wdrbiteten.gIivdeidnnboytasneaeetshthiselsisiat.,Whoewheavderdiotnweaastnimotespoeuctiafinedit wahsicchoannfitrimbioedticthwaatsagnitvibenio.tIicshheackdebdewenithgitvheenabnyaaensatheestihsetstioa,sheoewifetvherpitawtieanstncotuslpdehcaifvied wthheicahntainbtioibtioc tciec fwazaosligniv(eronu. tI icnheefcokretdhwe iptrhimthe).aHneaessatihdentiostatnodsteheatifhtehehapdatgieivnetncoanuoldthearve tahnetibaniottibici.oAtisc Icheafadzoalrinea(rdoyuptiuntecfeofar ztohleinpirnimey).pHuemspaidatntoheantdimtehaotuhtecohnafdirgmivaetnioann, oththeer adnetcibsionticw. aAsmI haaddeatlorecahdayngpeutocuetftaozoalineiwn mcirycupiutmtopbaetstahfe.time out confirmation, the decision was made to change out to a new circuit to be safe.
GOOD CATCH - what went well That it was checked before cannulation which antibiotic the patient could have and GOOD CATCH - what went well Tahdaetcitsiwonaswcahsecmkaedebteofocrheancagnentuhleatciiorncuwithsiochthaentpibatioietnicttwheoupladtineontthcaovueldahraevaectaionnd.
DECEMBER 2023 | www.anzcp.org 8