Accidents or errors are only the tip of the incident iceberg. Through effective, nonpunitive incident reporting, which includes reports of near-misses and system problems in addition to actual accidents, the systems-approach allows the complete set of contributing factors underlying an accident to be understood and addressed. Feedback to participants and targeted improvement in the workplace is also important to demonstrate that incident data are being used appropriately, and to maintain high levels of on-going reporting and enthusiasm for the scheme. Drug administration error is a serious problem, which warrants a well-reasoned approach to its improvement.

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Background: Paramedics may be involved in the care of patients experiencing a health crisis associated with palliative care. However, little is known about the paramedic’s role in the care of these patients. Aim: To describe the incidence and nature of cases attended by paramedics and the care provided where the reason for attendance was associated with a history of palliative care. Design: This is a retrospective cohort study. Setting/participants: Adult patients (aged >17 years) attended by paramedics in the Australian state of Victoria between 1 July 2015 and 30 June 2016 where terms associated with palliative care or end of life were recorded in the patient care record. Secondary transfers including inter-hospital transport cases were excluded. Results: A total of 4348 cases met inclusion criteria. Median age was 74 years (interquartile range 64–83). The most common paramedic assessments were ‘respiratory’ (20.1%), ‘pain’ (15.8%) and ‘deceased’ (7.9%); 74.4% (n = 3237) were transported, with the most common destination being a hospital (99.5%, n = 3221). Of those with pain as the primary impression, 359 (53.9%) received an analgesic, morphine, fentanyl or methoxyflurane, and 356 (99.2%) were transported following analgesic administration. Resuscitation was attempted in 98 (29.1%) of the 337 cases coded as cardiac arrest. Among non-transported cases, there were 105 (9.6%) cases where paramedics re-attended the patient within 24 h of the previous attendance. Conclusion: Paramedics have a significant role in caring for patients receiving palliative care. These results should inform the design of integrated systems of care that involve ambulance services in the planning and delivery of community-based palliative care.

There is limited literature regarding the treatment of unstable slipped capital femoral epiphysis (SCFE). The Evidence Analysis Work Group (EAWG) initiated a questionnaire assessing management of unstable SCFE by the members of the Pediatric Orthopaedic Society of North America (POSNA). All members were surveyed by e-mail and fax. The survey was accessible through the POSNA web site. One third of the members responded. Seventy-three percent of members used the "stable/unstable" classification, while 27% used the "acute/chronic" terminology. Thirty-one percent of respondents felt that an unstable SCFE is an emergency, while 57% felt that treatment could be on an urgent (<8 hours) basis. Fifty-seven percent reported use of a single threaded screw for fixation for an unstable SCFE, and 40.3% recommended two threaded screws. There seems to be agreement on methods of patient evaluation, but discrepancies remain in classification and fixation methods. The EAWG recommends development of multicenter studies to evaluate the treatment of unstable SCFE.

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This paper discusses an anonymous incident reporting scheme to reduce drug administration error on the hospital ward, as part of an effective, non-punitive, systems-focused approach to safety. Drug error is costly in terms of increased hospital stay, resources consumed, patient harm, lives lost and careers ruined. Safety initiatives that focus, not on blaming individuals, but on improving the wider system in which personnel work have been adopted in a number of branches of health care. However, in nursing, blame remains the predominant approach for dealing with error, and the ward has seen little application of the systems approach to safety. Safety interventions founded on an effective incident scheme typically pay for themselves in terms of dollar savings arising from averted harm. Recent calls for greater health-care safety require finding new ways to make drug administration safer throughout the hospital, and the scope for such safety gains on the hospital ward remains considerable.

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