Lest we forget: Learning and remembering in clinical practice

Anaesthesia

Volumn 68, Issue 11, 2013, Pages 1099-1103

  Smith, A ^a  

^a ROYAL LANCASTER INFIRMARY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

GLUCOSE;

CLINICAL COMPETENCE; CLINICAL PRACTICE; GLUCOSE BLOOD LEVEL; HUMAN; HYPOGLYCEMIA; INTENSIVE CARE; INTENSIVE CARE UNIT; MEDICAL EDUCATION; MEDICAL ERROR; PATIENT SAFETY; PRACTICE GUIDELINE; REVIEW;

BLOOD SPECIMEN COLLECTION; GLUCOSE; HEALTH CARE SURVEYS; HUMANS; HYPOGLYCEMIA; INTENSIVE CARE; MALE; MEDICATION ERRORS; PATIENT SAFETY; VASCULAR ACCESS DEVICES;

EID: 84885955965     PISSN: 00032409     EISSN: 13652044     Source Type: Journal    
DOI: 10.1111/anae.12412     Document Type: Review

References (33)

1. Gupta KJ, Cook TM,. Accidental hypoglycaemia caused by an arterial flush drug error: a case report and contributory factors critical analysis. Anaesthesia 2013; 68: 1178-87.
2. Leslie RA, Gouldson S, Habib N, et al. Management of arterial lines and blood sampling in intensive care: a threat to patient safety. Anaesthesia 2013; 68: 1114-19.
3. Sinha S, Jayaram R, Hargreaves CG,. Fatal neuroglycopaenia after accidental use of glucose 5% solution in a peripheral arterial cannula flush system. Anaesthesia 2007; 62: 615-20.
4. Lawton R, McEachan RR, Giles SJ, Sirriyeh R, Watt IS, Wright J,. Development of an evidence-based framework of factors contributing to patient safety incidents in hospital settings: a systematic review. British Medical Journal Quality and Safety 2012; 21: 369-80.
5. Russell T, Riazi S, Kraeva N, Steel AC, Hawryluck LA,. Ecstacy-induced delayed rhabdomyolysis and neuroleptic malignant syndrome in a patient with a novel variant in the ryanodine receptor type 1 gene. Anaesthesia 2012; 67: 1021-4.
6. National Patient Safety Agency. Problems with infusions and sampling from arterial lines. Rapid Response Report, 2008. NPSA/2008/RRR006. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59891 (accessed 11/07/2013).
7. Kim SY, Lee JS, Kim WO, Sun JM, Kwon MK, Kil HK,. Evaluation of radial and ulnar blood flow after radial artery cannulation with 20- and 22-gauge cannulae using duplex Doppler ultrasound. Anaesthesia 2012; 67: 1138-45.
8. Carthey J, Walker S, Deelchand V, Vincent C, Harrop Griffiths W,. Breaking the rules: understanding non-compliance with guidelines. British Medical Journal 2011; 343: d5283.
9. Kearns RJ, Moss L, Kinsella J,. A comparison of clinical practice guidelines for proximal femoral fracture. Anaesthesia 2013; 68: 159-66.
10. Smith A, Alderson P,. Guidelines in anaesthesia: support or constraint? British Journal of Anaesthesia 2012; 109: 1-4.
11. National Patient Safety Agency. Reducing the risk of hyponatraemia when administering intravenous infusions to children. Safety Alert, 2007. NPSA/2007/22. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59809 (accessed 13/08/2013).
12. Paddle JJ, Eve RL, Sharpe KA,. Changing practice with changing research: results of two UK national surveys of intensive insulin therapy in intensive care patients. Anaesthesia 2011; 66: 92-6.
13. Harrop-Griffiths W,. Never Events. Anaesthesia 2011; 66: 158-62.
14. Bowman S, Raghavan K, Walker IA,. Residual anaesthesia drugs in intravenous lines-a silent threat? Anaesthesia 2013; 68: 557-61.
15. Medical Devices Agency Hazard Notice HN 9702, 1997. Cited in: www.medidex.com/archive/764-smtl-newsletter-vol-1-no1-oct-1997.html (accessed 13/08/2013).
16. Bell D,. Recurrent wrong-route drug error-a professional shame. Anaesthesia 2007; 62: 541-6.
17. Carter JA,. Checking anaesthetic equipment and the Expert Group on Blocked Anaesthetic Tubing (EGBAT). Anaesthesia 2004; 59: 105-7.
18. Department of Health. An Organisation with a Memory. London: Stationery Office, 2001.
19. Smith AF, Pope C, Goodwin D, Mort M,. What defines expertise in regional anaesthesia? An observational analysis of practice. British Journal of Anaesthesia 2006; 97: 401-7.
20. Smith AF, Glavin R, Greaves D,. Defining excellence in anaesthesia: the role of personal qualities and practice environment. British Journal of Anaesthesia 2011; 106: 38-43.
21. Chambers WA, Smith WCS,. Case reports of novel treatments-proper evaluation before clinical use. Anaesthesia 2011; 66: 539-40.
22. Bogod D,. Nothing new under the sun: the Legacy Project for Anaesthesia. Anaesthesia 2007; 62: 545-6.
23. Cassidy CJ, Smith AF, Arnot-Smith J,. Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-8. Anaesthesia 2011; 66: 879-88.
24. Arnot-Smith J, Smith AF,. Patient safety incidents involving neuromuscular blockade: analysis of the UK National Reporting and Learning System data from 2006 to 2008. Anaesthesia 2010; 65: 1106-13.
25. Maclennan A, Smith AF,. An analysis of critical incidents relevant to paediatric anaesthesia reported to the UK National Reporting and Learning System, 2006-2008. Pediatric Anesthesia 2011; 21: 841-7.
26. Thomas AN, Taylor RJ,. Review of patient safety incidents reported from critical care units in North-West England in 2009 and 2010. Anaesthesia 2012; 62: 706-13.
27. Smith AF, Mahajan RP,. National critical incident reporting: improving patient safety. British Journal of Anaesthesia 2009; 103: 623-5.
28. Runciman WB, Kluger MT, Morris RW, Paix AD, Watterson LM, Webb RK,. Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Quality and Safety in Health Care 2005; 14: e1.
29. Magee P,. Checking anaesthetic equipment: AAGBI 2012 guidelines. Anaesthesia 2012; 67: 571-4.
30. Association of Anaesthetists of Great Britain and Ireland. Checking Anaesthetic Equipment 2012. Anaesthesia 2012; 67: 660-8.
31. Mellin-Olsen J, Staender S, Whitaker DK, Smith AF,. The Helsinki declaration for patient safety in anaesthesiology. European Journal of Anaesthesiology 2010; 27: 592-7.
32. Wilson IH, Walker IA,. Theatre checklists and patient safety. Anaesthesia 2008; 63: 921-3.
33. De Hert S, Imberger G, Carlisle J, et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. European Journal of Anaesthesiology 2011; 28: 684-722.