Two deaths due to head trauma related to use of a mechanical hoist and a lift chair could happen in any aged care home. The lessons for improving practice go beyond the actual cases as illustrated by the accompanying reflective exercises. Commentaries provide insights into recall bias, quality improvement rounds, cognitive testing and parallels with motorised mobility scooters.Episode Contents

• 01:08 Editorial

• 06:00 Case #1 Four tales

• 13:32 Brainstorming about the case: views from our nursing colleagues (Case #1)

• 16:05 Commentary #1: A literal approach—recall bias

• 20:06 Commentary #2: Contemplating care—quality improvement rounds

• 23:51 Case #2 ...