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Medical error is an important cause of morbidity and mortality. Organisational failure in the pre-operative period has been associated with catastrophic outcome. Little information is available regarding peri-operative organisational problems. The incidence and nature of organisational failure before urgent and emergency surgery in a district general(More)
The radiographer I am today is not the same radiographer I was in 1982 – my role has changed. This change did not occur by chance; it may have started out as an organic process but ended up as something that was directed and intentional. This paper reflects on my experiences in driving and advocating cultural change in radiography in my hospital and beyond.(More)
Heat and moisture exchangers (HMEs) humidify, warm and filter inspired gas, protecting patients and apparatus during anaesthesia. Their incorporation into paediatric anaesthetic breathing systems is recommended. We experienced delays in inhalational induction whilst using a Mapleson F breathing system with an HME. We have demonstrated that the HME(More)
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