Learning from Patient Safety Incidents


by Jeremy Groves, Consultant, Critical Care and Anaesthesia

I was helping out this morning with a bronchoscopy on a patient with a significant sputum load. My colleague Tim, who was supervising one of our trainees, Naomi, who was steering the scope, couldn’t see the wall mounted monitor.  I commented that the patient’s ventilation was being compromised by the presence of the scope. Tim wanted to see what was going on and asked me to turn the monitor towards him.  This I did and, with rather a large crash, a yelp from Naomi and a gasp of surprise from the rest of us, the monitor fell off the wall.

Fortunately it missed the patient but on its descent it grazed Naomi and caused a dreadful tangle.  The battery powered slave monitor kept functioning and, once detangled from the cats cradle of wires, was a godsend.

The monitor was not the latest piece of kit and rather heavy.  When the medical engineers inspected the fixings it would appear that the standard fixing kit had not been used.  Needless to say they are now checking out the screws holding up the rest of our monitors.  A Datix form has been completed.

This little incident came hot on the heels of an email from Dawn at the Faculty.  She has created a page on their website called ‘learning from patient safety incidents’- https://www.ficm.ac.uk/safety-and-clinical-quality/learning-patient-safety-incidents.

Now to my mind anything that can help stop avoidable mistakes is a good thing.  Reporting incidents to our work place based systems is right and proper but, though these are fed into the national incident learning system, I think the system can be a bit sluggish in wider feedback.

So the next time you are reporting an incident on your local reporting system that could have relevance to others working in critical care, consider logging it via the FICM website too.  You can either fill in the web form on the Faculty’s site or send a description through to Dawn (DTillbrook-Evans@rcoa.ac.uk)  and she will transfer the information to the template form prior to upload to the website.

After all, if we had considered checking the screws holding up our monitors we could have avoided an awful lot of hassle.