The June 2016 edition of Clinical Communique (a periodic report released by the Victorian Institute of Forensic Medicine) once again highlights the issues facing procedural healthcare. The report highlights three recent coronial inquests into patients who succumbed to complications from central access devices, including a fatal myonecrosis, a pericardial tamponade and a carotid placement resulting in a stroke. Multiple issues are highlighted in the insertion and subsequent management of these devices.
My problem with this is that we’ve heard it all before. There is nothing new in these recommendations, yet the incidents keep happening. And it’s far too simplistic to think of the clinical staff involved as “bad apples”. Simple fact is, they are not. They are hard working, intelligent, dedicated, diligent and well intentioned. In fact, they’ll no doubt be completely traumatised by the experience. So why does this keep happening?
Off the top of my head, let’s start with the following :
a) a lack of agreement on best approach (but there ARE existing guidelines)
b) failure to communicate guidelines effectively to those at the coalface
c) resistance by clinicians to embrace best available evidence
d) total lack of structured accreditation process for insertion of lines (and most other invasive procedures)
e) systemic failure to share learnings just like this on a wide enough scale
Surely its time our industry got its act together and did something meaningful to overcome these barriers.
If you’re interested, here’s the report
About the author
Dr Todd Fraser is an intensivist and retrieval physician, and the co-founder of the Osler Clinical Performance Platform, dedicated to improving certification and training in acute healthcare.
