• The Communiqués

Clinical Communiqué Volume 9 Issue 3 September 2022

Download PDF:  Clinical Communiqué September 2022 Edition


In this edition

  • Editorial

  • Case #1: An alarming error

  • Case #2: Deteriorating or not?

  • Expert Commentary: Perspectives on risk mitigation and alert fatigue

Welcome to the third edition of the Clinical Communiqué for 2022. Our readers will recall that our previous edition, the Clinical Communiqué June 2022, was our milestone 20-year edition, and we were honoured to mark the occasion with a collection of compelling and insightful commentaries from leaders in the patient safety movement of the past two decades.


It was a substantial edition, our biggest undertaking to date, with an enormous amount of content to digest. Our experts offered their lessons learned and sage guidance for a better future, crafted from a wealth of knowledge, experience and determination in their hard-fought efforts to improve the quality and safety of patient care.


I strongly recommend that you revisit the edition as you will discover more gems each time you come back to it. Use the commentaries as a platform for ideas that you want to test or introduce in your own workplaces. Discuss the ideas with your peers, in your tea breaks, handovers, journal clubs, teaching sessions, and at grand rounds. Momentum is the key to achieving change, and collective efforts to drive action is what will bring about systems changes in healthcare.


In this edition, we return to our familiar format of presenting coroners’ case summaries with an expert commentary that explores some of the themes identified in the cases. We highlight two cases, both involving post-operative patients, where electronic alerts were overridden and criteria for escalation were met but not actioned. These cases introduce the concept of alarm/alert fatigue (terms used interchangeably) and failure to escalate care/failure to rescue.


This publication has regularly focused on learning from recurring errors. Things that keep happening but shouldn’t. Whether it is alarm fatigue from multiple alerts that cause annoyance and fade into seeming inconsequence before being deleted from the desktop of consciousness, or a failure to escalate care due to a confusion between ‘not changing’ and ‘stable’, the commonality is a lack of focused attention. For an individual this can be exacerbated by fatigue or the ‘automatic processing’ type of thinking that occurs when performing routine tasks. For a team, the relative strength of an alert signal can be muffled by barriers to communication, a perceived lack of safety in speaking up, and a tendency towards ‘belief similarity’ with the person immediately occupying the highest point of the hierarchy.


How can we develop our teams to share the burden of risk management responsibilities at every level and make safety behaviours the new model of success? We do this by using technology in a smart way to support our decisions, and creating environments where our teams understand risk and are not just empowered, but directed to re-focus our attention when needed.


Our expert commentary, which includes a sophisticated and holistic approach to risk management interventions, is by Dr David Bramley, a senior anaesthetist with extensive experience in designing safer systems in healthcare. He has worked on ANZCA’s Professional Guideline for the safe management and use of medications in anaesthesia, was Chair of Western Health Medication Safety Committee during Electronic Medical Record (EMR) implementation, and acted as a Consultant to the Victorian Therapeutic Advisory Group on a number of hospital safety issues. He is currently employing his clinical risk expertise in the most practical way possible, as the medical lead contributing to the design of a new build hospital.