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Anaesthesia News Safety Special Collection

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Safety issues

Individual safety articles 2014-2021

General – Articles

  • ‘Skydiving and anaesthesia- A vehicle for reflection on human factors?’- February 2014 
  • ‘Reflections on a drug error’- December 2014 
  • ‘On the job draining’- June 2015 
  • ‘Arterial line safety- can we do better?’ - August 2015 
  • ‘Reversal of non-depolarising neuromuscular blockade’- January 2016 
  • ‘The role of anaesthetists in setting equipment standards’- January 2017 
  • ‘Things you thought you would never do’- January 2017 
  • ‘What happens when I report something to MHRA?’- January 2017 
  • ‘What’s happening with non-Luer connectors?’- January 2017 
  • ‘What has NHS Improvement ever done for anaesthetists?’- January 2017 
  • ‘A view from the other ether’- January 2017 
  • ‘Red plunger syringes for neuromuscular blocking drugs’- March 2017 
  • ‘Restricted use of open systems for injectable medication- what does this mean for anaesthetists (and their gallipots)?’- March 2017 
  • ‘Delivering clinical safety on military operations’- January 2018 
  • ‘Of never events, safety standards and human error’- January 2018’ 
  • ‘When guidelines alone are not enough: introducing engineered solutions to patient safety’- January 2018 
  • ‘The Healthcare Safety Investigation Branch’- January 2018 
  • ‘An audit of trainee fatigue and wellbeing in the Yorkshire and the Humber Deanery’- March 2018 
  • ‘Chlorhexidine anaphylaxis: The challenges of creating a chlorhexidine-free environment for hypersensitive patients in secondary care’- August 2018 
  • ‘Capnography, tracheal intubation and cardiac arrest’- October 2018 
  • ‘Reporting device issues to MHRA’- January 2019 
  • ‘Have wrong sided regional blocks been overlooked?’- January 2019 
  • ‘Pioneers of patient safety’- January 2019 
  • ‘National Safety Standards for Invasive Procedures (NatSSIPs) - January 2019 
  • ‘A paradox in safety: Maslow v Care Quality Commission’- July 2019 
  • ‘The WHO Surgical Safety Checklist: eight years later, where do we stand?’- July 2019 
  • ‘Drug errors in anaesthetic practice’- January 2020 
  • ‘The first major change in European medical device regulation since 1993. How does it affect the Anaesthetist?’- January 2020
  • ‘The Quick Reference Handbook: managing perioperative crises’ - January 2020 
  • ‘NatSSIPs- beyond the operating theatre walls’- January 2020 
  • ‘Improving access to anaesthetic emergency equipment’- January 2020 
  • ‘New Equipment, New Hazards- Lessons from the USS John S McCain Collision’- January 2020 
  • ‘Radiation safety for pregnant anaesthetists’- January 2020 
  • ‘PERUSE before you infuse- a safety initiative for total intravenous anaesthesia’- July 2020 
  • ‘Rethinking patient safety’- February 2021 
  • ‘Effective learning from serious incidents’- February 2021 
  • ‘Healthcare safety investigations as a vehicle for improving patient care’- February 2021 
  • ‘Patient safety in the COVID era; an update from the SALG-BIDMC Safety Scholars’- February 2021 
  • ‘Risk of fire in ICUs, theatre suites and ICU escalation areas’- February 2021 
  • ‘The New Safe Anaesthesia Liaison Group standardised operating procedure for ‘Stop Before You Block’- ‘Prep, Stop, Block’- January 2022 
  • ‘Unrecognised oesophageal intubation’- January 2022 
  • ‘Experience with lipid rescue and local anaesthetic toxicity in Scotland- it could happen to you…’- January 2022

General – Correspondence

  • 'Dear Editor- An anaesthetic addition to the WHO Surgical Safety Checklist- Anaesthesia Shout Out!’- October 2014 
  • ‘Dear Editor- an unusual airway dilemma’- February 2015 
  • ‘Safety Matters’- March 2016 
  • ‘Dear Editor’- item around anaesthesia after Taser use on patients in custody- April 2017 
  • ‘Dear Editor- Metaraminol and the cost of safety’- August 2017 
  • ‘Dear Editor- The pen is as dangerous as the sword’- October 2017 
  • ‘Safety Matters- Theatre lighting: a potential cause of drug errors’- September 2018 
  • ‘Dear Editor- Anaesthetic room to operating theatre transfer checklist’- March 2019 
  • ‘Dear Editor- A technological advance in the management of diabetes… and a potential problem’- July 2019 
  • ‘Dear Editor- Communication with GPs’- October 2019 
  • ‘Dear Editor- A city-wide approach to airway alert systems’- March 2020 
  • ‘Dear Editor- Difficult airway management in patients wearing religious head-coverings’- April 2020 
  • ‘Dear Editor- Preoperative chewing gum- fasting is not all that matters?’- May 2020 
  • ‘Dear Editor- A suggestion for safe lung deflation during one-lung ventilation in COVID-19 suspect or positive patients’- June 2020 
  • ‘Dear Editor- Obstetric emergency- hyponatraemia’- August 2020 
  • ‘Dear Editor- COVID-19 airway assessment: unmasked’- December 2020 
  • ‘Dear Editor- High-‘lighting’ a potential airway safety issue’- May 2021 
  • ‘Dear Editor- A mouthful of surprise!!’- July 2021 
  • ‘Dear Editor- The dangers of using non-local apps for dosing of local anaesthetics’-September 2021

Equipment and drug problems – Articles

  • ‘Response to Coroner’s report to prevent future deaths’- February 2018 
  • ‘Withdrawal of a medical device- the Irish experience’- April 2020 
  • ‘Standardisation, syringe labelling and prefilled syringes’- February 2021 
  • ‘Preventing dual humidification errors in ventilation circuits’- May 2021 
  • ‘Arterial blood glucose error and insulin overdose: cause and solution’- May 2021 
  • ‘Selecting the wrong filter: a difficult patient safety issue’- January 2022

Equipment and drug problems – Correspondence

  • ‘Dear Editor- Who would have guessed?’- January 2014 
  • ‘Dear Editor- Anaesthetic circuit malfunction: a case we’ll never forget’- February 2014 
  • ‘Dear Editor- A change in appearance of paracetamol and metronidazole’- March 2014 
  • ‘Dear Editor- Airtraq Cuff Rupture’- March 2014 
  • ‘Dear Editor- I wanted to report an incident during a Category 3 Caesarean section’- April 2014 
  • ‘Dear Editor- The importance of a third person in the anaesthetic room’- April 2014 
  • ‘Dear Editor- Difficult to ventilate’- May 2014 
  • ‘Dear Editor- Faulty syringe’- May 2014 
  • ‘Dear Editor- Laryngeal mask airway’- May 2014 
  • ‘Dear Editor- Cracked soda lime canister’- May 2014 
  • ‘Dear Editor- Faulty cannula’- May 2014 
  • ‘Dear Editor- Paediatric circuit’- May 2014 
  • ‘Dear Editor- Needlestick risk with Chloroprep applicators’- June 2014 
  • ‘Dear Editor- Entanglement of endotracheal tube’- August 2014 
  • ‘Dear Editor- Defective ruptured arterial line’- October 2014 
  • ‘Dear Editor- When IV access puts a dampener on your day’- January 2015 
  • ‘Dear Editor- Propofol, the ‘aero effect’ and filter needles’- January 2015 
  • ‘Safety Matters’- February 2015 (4 items included) 
  • ‘Safety Matters’- March 2015 (2 items included) 
  • ‘Dear Editor- Faulty things and widgets- May 2015 (8 items included) 
  • ‘Safety Matters’- June 2015 (3 items included) 
  • ‘Dear Editor’- July 2015 (2 items included) 
  • ‘Safety Matters’- July 2015 (3 items included) 
  • ‘Dear Editor’- item regarding BIS monitoring and forced air warming devices- August 2015 
  • ‘Safety Matters’- September 2015 (2 items included) 
  • ‘Safety Matters’- October 2015 (2 items included) 
  • ‘Dear Editor- Ampoule dwarfism and sharps injuries’- October 2015 
  • 'Dear Editor- Recuronium: further evidence of the dangers posed by neuromuscular blocking drugs’- October 2015
  • ‘Safety Matters’- April 2016 (2 items included) 
  • ‘Dear Editor- Printing error on a laryngeal mask’- July 2016 
  • ‘Dear Editor- The Angled-Handle Trap!’- September 2016 
  • ‘Safety Matters’- October 2016 (4 items included)
  • ‘Dear Editor’- item regarding Omni-Tract clamp occluding/damaging a TIVA set- November 2016 
  • ‘Dear Editor- We report an unusual cause of tracheostomy air leak in the ICU’- February 2017 
  • ‘Dear Editor- Lost in transition: A problem with non-Luer connections’- March 2017 
  • ‘Dear Editor’- August 2017 (2 items regarding colour blindness & drug labelling) 
  • ‘Dear Editor’- September 2017 (item regarding metronidazole/saline similar packaging) 
  • ‘Safety Matters’- October 2017 (3 items included)
  • ‘Dear Editor- Pink allergy’- November 2017 
  • ‘Dear Editor- Is it time to change drug packaging colours?’- January 2018 
  • ‘Dear Editor- Not all pink is pink!’- February 2018 
  • ‘Dear Editor- Incorrectly assembled catheter mount’- April 2018 
  • ‘Dear Editor’- item regarding similar packaging of drugs/skin prep- May 2018 
  • ‘Dear Editor’- item regarding plastic ECG dot backing obstructing airway equipment- June 2018
  • 'Dear Editor’- item regarding torn reservoir bag on anaesthetic machine- August 2018 
  • ‘Dear Editor’- item regarding sharps bin design- January 2019 
  • ‘Dear Editor- Accidental lidocaine infusion’- February 2019 
  • ‘Dear Editor- A sticky situation: Sudden failure of injection through a cannula’- March 2019 
  • ‘Dear Editor- A faulty regional anaesthesia block needle’- April 2019 
  • ‘Dear Editor- Precipitation of intravenous diclofenac’- July 2019 
  • ‘Dear Editor- Syringe tip breakage’- August 2019 
  • ‘Dear Editor- Faulty spinal needle’- August 2019 
  • ‘Dear Editor- I’ve lost the end; no seriously, I’ve lost the end’- October 2019 
  • ‘Dear Editor’- item regarding midazolam labelling- January 2020 
  • ‘Dear Editor- Steep head-down position and a new problem’- January 2020 
  • ‘Dear Editor’- item regarding Opsite spray & epidural fixation device- March 2020 
  • ‘Dear Editor- Air through the crack- faulty equipment and a diagnostic problem’- April 2020 
  • ‘Dear Editor- Central venous catheter guidewire- a length mismatch’- May 2020 
  • ‘Dear Editor- Retained PICC guidewire fragment- caution with new equipment’—June 2020 
  • ‘Dear Editor- Keep up-to-date with device expiry’- September 2020 
  • ‘Dear Editor- GlideScope Auto Power Off – a nasty surprise’- February 2021 
  • ‘Dear Editor- Unexpected issue with bile bag connector’- March 2021 
  • ‘Dear Editor- Defective valve in a Venflon cannula’- May 2021 
  • ‘Dear Editor- Diagnostic problem during ultrasound-guided supraclavicular block- an iatrogenic cause’- May 2021 
  • ‘Dear Editor- If you feel a pop, stop!’- May 2021 
  • ‘Dear Editor- A latent error hiding in plain sight’- June 2021 
  • ‘Dear Editor- Glass particle contamination in propofol’- June 2021 
  • ‘Dear Editor- Always lubricate your TOEs well!’- July 2021 
  • ‘Dear Editor- Unidirectional block to passing guidewire through a central venous catheter’- July 2021 
  • ‘Dear Editor- Erroneous processed EEG waveform and Entropy readings from ECG interference’- August 2021
  • 'Dear Editor- Leaking intravenous extension set during total intravenous anaesthesia’- September 2021 
  • ‘Dear Editor- A faulty CO2 monitoring line: is pre-operative testing required?’- October 2021 
  • 'Dear Editor- Cracking of polycarbonate infusion set by propofol’- November 2021 
  • ‘Dear Editor- Faulty tracheostomy tube’- November 2021 
  • ‘Dear Editor- Drug concentration- in the eye of the beholder’- January 2022 
  • ‘Dear Editor- Always check the circuit before starting’- March 2022 
  • ‘Dear Editor- Hidden circuit leak – check soda lime canister’- March 2022