Safety and quality monthly update - July

Expressions of interest sought – National Blood Authority (NBA) Clinical /Consumer Reference Group (CRG) for Critical Bleeding Guideline

ANZCA representatives are sought for the NBA CRG to update the patient blood management guideline for adults with critical bleeding. Expertise is sought in peri-resuscitative, multidisciplinary management of adult patients with major haemorrhage. 

To express interest or to seek more information, contact [email protected] by 7 August.

NBA – archive of Patient Blood Management (PBM) guidelines 

The NBA is archiving its PBM Guidelines (Modules 2–6) because they are older than 10 years old and the evidence upon which they are based is outdated. Notwithstanding, the PBM guidelines:

Until new PBM guidelines are published, members should continue to refer to archived guidelines, supplemented by more recent guidance from Europe, the United Kingdom and North America, when appropriate to do so in an Australian and New Zealand context. 

Once published, the new guidelines will immediately supersede previous, and other jurisdictional, guidance.

The Australian Council on Healthcare Standards (ACHS) Root Cause Analysis (RCA) workshop

On 11 August, the ACHS is holding a 3-hour online RCA report writing workshop. 

ACSQHC Venous Thromboembolism Prevention (VTE) Clinical Care Standard (CCS) review

As part of its review, the ACSQHC is inviting clinicians to complete a survey about the VTE CCS 2020 to help identify priorities. Survey closes Friday 31 July. 

Griffith University study about peripheral intravenous catheter (IV) care 

Griffith University is seeking hospital-based clinicians – who are involved in the care, surveillance or policy making for peripheral IV catheters – to be interviewed for the research project: Investigating barriers and facilitators to implementing clinical standards for peripheral intravenous catheter care in Australia. Please express interest via the EOI form.

ACSQHC Open Disclosure Framework (ODF) 2026

The ACSQHC has published the revised Australian Open Disclosure Framework, which marks a significant milestone in strengthening transparency and person-centred care across the Australian health system.

ANZCA Essential Medications List

ANZCA has published an Essential Medications List with details of medications that are considered key to the safe and effective provision of anaesthesia and pain medicine care in Australia and New Zealand. In cases of severe supply disruption of critical medications for anaesthesia and pain medicine, the list details alternatives. The list has been promoted through national and jurisdictional networks in both countries, and will be periodically updated. For queries or to provide feedback, please email us. 

WebAIRS: A case of intraoperative hypothermia

Medical device issues are often multifactorial. In a recent incident reported to webAIRS, a forced-air warming hose became detached from the warming blanket during surgery, resulting in intraoperative hypothermia. The disconnection was difficult to detect because it was obscured by the patient’s position on the operating table.

Contributing factors may have included unfamiliarity with equipment or local processes, environmental factors, and distraction associated with a complex clinical situation.

Equipment-related incidents are rarely caused by device failure alone. Human factors, equipment design, workspace layout, and workflow all influence how easily problems are detected and corrected.

Have you experienced a medical device or equipment issue in your department? 

If so, consider reporting it to webAIRS  Even seemingly minor events can identify recurring system vulnerabilities and help prevent future patient harm.

For further information: [email protected]