Obstáculos para la #SegPac: Dispersión – Pt Safety Network

9. Dispersion

When an aeroplane crashes hundreds often die. This concentration of deaths lends the aviation industry tremendous energy in ensuring the same adverse event doesn’t happen again. Healthcare rarely benefits from the same fate.

‘Over the last few years NSW Health have received numerous reports of death and morbidity from central line related air emboli’.

This statement in itself is a ‘call to action’.

‘Why don’t we know about this already, how is it happening, what’s already been done and what can we do to stop this’. (see here)

While these adverse events undoubtedly happen throughout the world, NSW have performed extremely well in identifying this cluster of similar incidents.  Presented as a cluster, where the problem is happening to so many, our tendency is to concentrate more on the systems and devices we interact with.

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