READ and IMPORTANT PATIENT SAFETY INFORMATION

Created - 27.03.2015

READ and Important Patient Safety Information

1. RCR members will shortly receive the latest READ (Radiology Events and Discrepancies) newsletter in hard copy format. It revisits the patient safety film "The System" which is available on the BSIR website. BSIR members were closely involved in its production and it details relevant learning cases. Please consider whether such events could happen in your own department. BSIR members are encouraged to submit relevant cases to READ via the RCR website.

2. NHS England has recently received notification about a serious untoward incident involving the inadvertent injection of chlorhexidine during angiography that occurred in an acute Trust in 2014. This event, and the learning following its investigation, has been the subject of a 'safety video’, released through YouTube, made by the Trust, the patient and a human factors specialist from the aviation industry. 

Members are requested to watch the video (about 20 minutes) and bring it to the attention of other staff in their department, especially given that it is not an isolated incident and similar events have occurred with inadvertent injection of glue and thrombin. Again please consider whether your department really is immune from similar events.

https://www.youtube.com/watch?v=IJfoLvLLoFo

BSIR Patient Safety and Quality Committee