Welcome to the first edition of the Clinical Communiqué for 2019. In this edition, we discuss fixation error, the phenomenon whereby a person or group falls into a pattern of thinking that there is only one possible explanation. This can take on several forms, including task fixation on a procedure, or diagnostic fixation to the exclusion of other possibilities, as unfortunately demonstrated in the two cases presented.
Welcome to the winter 2017 edition of the Clinical Communiqué. Since our last edition, we have seen interest in our publication continue to grow, and we have been heartened by the feedback we continue to receive from our readers about the lessons learned.
Welcome to the final issue for 2016. In this issue we look at three cases where medication errors contributed to the cause of death. There is extensive literature available on the types of medications errors, their prevalence, and the hard work that has been done so far to reduce this substantial cause of adverse events in healthcare settings. The Australian Commission on Safety and Quality in Healthcare identified the importance of improving the safety and quality of medication usage in Australia, and listed it as a National Safety and Quality Health Service Standard (NSQHS Standard 4).
In our first issue for 2016, we look at three cases where deaths occurred as a result of complications arising from day procedures. None of the cases were urgent and in two cases the procedures were sought by the patients for cosmetic benefits and perceived lifestyle enhancement.