Incident related to “corner cutting” | n ( = 15) |
---|---|
Ventilator/circuit failure due to no/poor checking | 6 |
Temp set too high on humidifier | 1 |
Partial extubation during movement | 2 |
Throat pack left in | 1 |
Missed oesophageal intubation | 1 |
Uncrossmatched blood given | 1 |
Nerve block wrong side | 1 |
Suxamethonium given by mistake after intubation | 1 |
C1 fracture missed pre-op—not viewed by radiologist | 1 |