ICU Management & Practice, Volume 16 - Issue 2, 2016

Patientsafe represents a group of healthcare staff focused on introducing effective and sustainable healthcare solutions. ICU Management & Practice emailed the team to find out more about their Twitter account and blog.

Your Twitter strapline is "Front Line Staff Implementing Effective Safety Solutions” Who’s behind patientsafe?

Patientsafe started as a small group of three critical care subspecialty doctors. Our group has gradually grown to incorporate several frontline staff—doctors, nurses, and technicians. We collaborate closely with leaders from several healthcare backgrounds.

We have a particular focus on patient safety from the human factors perspective. We believe this is an untapped and poorly understood field that could be of great benefit in reducing adverse events. We have all witnessed avoidable adverse events and are driven to prevent them recurring.

We would like to note the influence of Dr Terry Fairbanks (human factors) and Dr Ronald Heifetz (adaptive leadership) as having particular impact on our work.

How can social media help to bring patient safety “front of mind” to healthcare staff?

Our posts have two overall themes:

  • The human factors approach to patient safety;
  • Specific hazards that exist in the workplace.

Social media has enabled us to connect with numerous individuals and groups who share a similar interest. With their feedback they have in turn helped polish our work, which is continually evolving.

Why a blog about patient safety?

We have been bestowed with the knowledge that patient safety could and should be much better. Unfortunately with existing safety frameworks this can feel like a curse.

The continued presence of obvious hazards in the workplace enlightens us to the difficulties in improving patient safety systems.

Can you share any success stories where you have helped make a difference to patient safety?

We have had some success in removing hazards from individual hospitals, particularly Adjustable Pressure Limiting (APL) valves and almost colourless antiseptic solutions. We have exposed the difficulties in removing these from all healthcare workplaces using current safety systems.

We are aware that some hospitals have removed attachments that open to air from their central lines—a hazard that unnecessarily risks air emboli. We have discovered a central line that does not open to air and await Therapeutic Goods Administration (Australia) approval prior to trialling it.

We have developed a Hazard Feedback Framework (, which we believe may be used by any frontline staff member in developing a proposed solution to a safety hazard. Through its use we hope staff will become better educated about the human factors approach to healthcare safety, while helping to remove identified hazards from their workplace.

There are several specific safety hazards that we continue to work on, including:

  • Ensuring immediate availability to adequate doses of Sugammadex in operating theatres;
  • Central line management to reduce air embolus risk;
  • Use of laryngoscopes that allow simultaneous video and direct laryngoscopy as first line for intubation.
  • Replacement of forced air warmers with active warming blankets where appropriate. We are always learning.
We recognise that all healthcare staff are dedicated to patient safety and providing optimal outcomes. We would like to help in generating an environment which allows this to happen.