VN06 Anaesthesia - Sources of medical or human error by DWA https://padlet.com/dwa2023/f9nw54wugchkqcs9 Add ideas of potential medical or human error and how they could be prevented en-us 2025-04-22 15:15:43 UTC 2025-05-07 10:30:54 UTC hello@padlet.com https://padlet.net/icons/png/1f628.png https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439745368 APL valve not open

]]> 2025-05-07 10:27:23 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439745368 https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439745529 Mis-calculation of drugs

]]> 2025-05-07 10:27:31 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439745529 Miscommunication https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439745563 2025-05-07 10:27:33 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439745563 Circuit errors https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746047 Errors with the circuit - wrong size, not working, tear in the bag, not filling adequately.

Prevented by checking the circuit thoroughly before every anaesthetic

]]> 2025-05-07 10:27:56 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746047 https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746151 Walking out of room

]]> 2025-05-07 10:28:02 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746151 Not filling up Isoflurane https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746187 2025-05-07 10:28:05 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746187 Faulty equipment being used https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746520 2025-05-07 10:28:23 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746520 Wrong monitoring equipment out too small BP cuff https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746601 2025-05-07 10:28:28 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746601 Equipment not set up beforehand https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746642 2025-05-07 10:28:31 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746642 Not having oxygen turned on https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746870 2025-05-07 10:28:49 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746870 Misunderstanding of instructions from VS https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746905 2025-05-07 10:28:52 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746905 https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746911 Circuit not checked prior to use

]]> 2025-05-07 10:28:52 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746911 Running out of oxygen https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746974 Prevented by - checking oxygen tank before every anaesthetic and changing when low so there's enough for all procedures of the day

]]> 2025-05-07 10:28:57 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439746974 Scavenging not attached https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747091 2025-05-07 10:29:03 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747091 Wrong sized ET tube https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747455 2025-05-07 10:29:20 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747455 Incorrect ET tube sizing/cuffing https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747470 2025-05-07 10:29:21 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747470 not leak checking circuit prior to use https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747730 2025-05-07 10:29:33 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747730 https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747760 Not starting iso/oxygen again after moving through

]]> 2025-05-07 10:29:35 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747760 Not double checking machine readings with manual ones https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747865 2025-05-07 10:29:39 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747865 Meds not labeled https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747892 2025-05-07 10:29:42 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747892 Incorrect depth of anaesthesia https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747961 2025-05-07 10:29:44 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439747961 Wrong pre-med https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439748296 Wrong drug or miscalculated dose, not drawn up correctly

Prevented by - having 2 people (1 of them being the vet) check the dose and the amount drawn up before administering

]]> 2025-05-07 10:30:04 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439748296 https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439748496 Not refilling isoflurane and running out

]]> 2025-05-07 10:30:14 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439748496 No recent stock check of suture material or Crash kit https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439748668 2025-05-07 10:30:22 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439748668 Lack of competency? https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439749258 Eg. Not raising concerns about whether you’re comfortable in a situation.

]]> 2025-05-07 10:30:53 UTC https://padlet.com/dwa2023/f9nw54wugchkqcs9/wish/3439749258