We would like to report a ‘near miss' critical incident that occurred with the use of Activated Protein C (APC). It has raised a number of issues, which highlight the importance of safety, continuity of care and handover.
BernardGREfficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med2001;344: 699–709.
2.
FumagalliRMigniniMA. The safety profile of drotrecogin alfa (activated). Crit Care2007;11: S6.
3.
AuzingerGO'CallaghanGPBernalWPercutaneous tracheostomy in patients with severe liver disease and a high incidence of refractory coagulopathy: a prospective trial. Crit Care2007;11: R110.
4.
Department of Health. An Organisation with a Memory. HMSO, 2000.
5.
British Medical Association. Safe Handover: Safe Patients-Guidance on Clinical Handover for Clinicans and Managers. BMA PressLondon. 2004.
6.
ICS and IBTICM Standards. Standards for Consultant Staffing of Intensive Care Units. 2006.