Valvular Insufficiency

Take a look at the image below and see if you can spot the differences between these two IV giving sets:

Maybe the packaging will help?

How did you go? There are actually a few differences between them, but there is one in particular that I am interested in, and you should be too. Can you guess which one it is? Yes, that little white bit circled in red is what’s called a “one-way”, “back check” or just “check” valve. As the name suggests it ensures fluid in the line can only move one-way i.e. from the IV fluid bag and into the patient. This valve is there so that if you are running a secondary infusion it will flow into the patient, rather than back up the primary line and into the fluid bag. A visual representation of what this valve does can be seen in this video:

Continue reading “Valvular Insufficiency”

The Fastest Surgeon on Earth

I had the privilege of giving a presentation at the Annual Scientific Meeting of the Australian & New Zealand College of Anaesthetists in May 2018. Below is a pre-recorded version of my presentation.

The Fastest Surgeon on Earth from Dr Getafix on Vimeo.

EHRs: Safety vs Privacy & the ETTO Principle

A little while back I posted about the challenges a family member faced after forgetting to bring their medications when they came to visit us. In that post, I referred to the Electronic Transfer of Prescriptions  (eTP) and I’ve now taken a closer look at this system and discovered some useful features, but also significant room for improvement and expansion.

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Travelling, Medications and Patient Work

Edit 18/5/2018: A follow-up to this post can be found here.

My parents, as they often do, came up to Newcastle and stayed for a few nights last week, and it ended up being a case study in Patient Work.

My mother left all her medications at home. I’m sure she’s not the first, and won’t be the last person to make this kind of skill-based error known as a “lapse”, but it immediately raised some obvious questions and issues that she, and others, had to go about solving, requiring significant amounts of time and mental effort which all contributed to her Patient Workload. Continue reading “Travelling, Medications and Patient Work”

A Challenge to Cloth Theatre Caps?

In recent months the “Theatre Cap Challenge” has been picking up steam on Twitter & has had significant coverage on mainstream media as well. In case you’re wondering what all the fuss is about, you can check out my video in this post or check out the twitter feed below.

While it’s been great seeing this initiative gain momentum, it seems that a significant number of people are hitting a hurdle in adopting it because their hospital doesn’t allow reusable cloth caps citing infection control concerns. In Australia, the ACORN standard is usually cited as the reason for not allowing them, though not all hospitals are interpreting the standard in the same way, and the standard itself allows individual hospitals to develop their own policy on cloth caps.

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What’s in a name?

As part of my job, I have a monthly safety spot at our departmental M&M meetings. Here is a modified version of one of the presentations discussing the importance of knowing, and using, people’s names. If you would like to download a copy of the slides, you can do so here here.

What’s in a name? from Dr Getafix on Vimeo.

The “names-on-caps” idea came from Rob Hackett and then went viral after Alison Brindle started the hashtag #TheatreCapChallenge.

Patient Work in the Twitterverse

Following my recent post on Patient Work, I decided to do what i normally do when I want to research something and headed over to Twitter. I did a search using the hashtag #PatientWork and was surprised to discover that at that time (2/3/18) there was a total of only 25 tweets, the earliest one being from 2012. Furthermore, 5 of them were mine, and 7 were used in a sense that was unrelated to what I was interested in leaving only 13 of relevance to me that predated my interest in the topic! I think this confirms Holden’s opinion (quoted in my earlier post) that this area is under-represented in the HF/E area. I might have to see if I can do something about that!


Patient Work

One of the (many!) things I love about Human Factors/Ergonomics (HF/E) specialists is that a large chunk of their work involves studying, describing and naming “everyday” human experiences. So when I am listening to their presentations or reading their articles, it is not uncommon for me to have an “A-ha!” moment where they describe something that is very familiar to me. “Oh, that’s what that’s called!” or “Phew! I thought I was the only one that did that sort of thing!”. A relatively recent example of this for me was as at the Human Factors and Ergonomics Society of Australia conference (HFESA17) last year. This time, the everyday experience that now had a name was “Patient Work”. Continue reading “Patient Work”

Quick Thinking and Natural Disasters

I’m currently reading Daniel Kahneman‘s book “Thinking, Fast and Slow” and while reading the chapter on the “availability heuristic”, a real-world example popped up in my news feed. To explore this further, consider the following question:

Please rank the following natural disasters in order of the number of deaths caused in Australia:

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These are the deadliest times for traffic collisions

This is a rather sobering infographic on road fatalities in Australia. This is a complex problem so using simple, reductionist solutions won’t work. Instead we need to use a systems thinking approach. This quote sums it up pretty well:

“We know in road safety that focusing on individual behaviour is not helpful … You actually have to change the system so that when people make mistakes they’re not penalised by dying.”

These are the deadliest times for traffic collisions

These are the deadliest times for traffic collisions

New figures reveal the most dangerous times to be on the road for young drivers, cyclists, pedestrians and other road users.