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Check, check, and check(list) again

Last post 25 Oct 2018, 10:11 PM by Alistair Maddock. 0 replies.
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  •  25 Oct 2018, 10:11 PM 2675

    Check, check, and check(list) again

    Akuji described the accidental cutting of an oxygen hose by a trolley wheel, during intrahospital transfer to the computed tomography scanner [1]. 

    At the Emergency Medical Retrieval Service, based in Glasgow, we perform secondary, mostly aero-medical, transfers of approximately 250 patients per year, with extensive use of checklists and cognitive aids to facilitate our work. On our 'Ready To Go' checklist, performed just before departure from a referring centre, one of the items checked by the transfer team is "snag risk minimised," which prompts colleagues to ensure that all infusion lines, monitoring cables and other equipment, are secured inside the vacuum mattress being used to transfer the patient. This check aims to prevent such items catching on various hazards encountered during retrieval missions, which may last several hours and involve movement on and off several transport platforms. Our local Health Board has adopted a similar checklist for both intra- and inter-hospital transfers, with a similar question about snag risks. Neither checklist is time consuming, or burdensome.

    The use of such a checklist could have served as a prompt to ensure oxygen hoses were not in a potentially vulnerable position in the case described. Despite our Service's high level of familiarity with transfer medicine, we find such prompts useful and suggest that for hospital colleagues, undertaking transfers with less frequency, they may be even more so. We would like to invite Dr. Akuji to comment on whether a checklist was used, and/or whether the hospital concerned has considered introducing a 'snag check' in any transfer documentation as a result of this incident, to help prevent any recurrence.  

    A. Maddock

    A.J. Cadamy

    Emergency Medical Retrieval Service,

    Glasgow, UK.

    Email: alistair.maddock@nhs.net


    No external funding and no conflicts of interest declared.



    1. Akuji M. Burst oxygen hose. Anaesthesia 2018; 73: 1436. ‚Äč

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