Beruflich Dokumente
Kultur Dokumente
full publication:
Patient Safety Update including the summary of reported
incidents relating to anaesthesia 1 January to 31 March
2015.
ON THE SALG
AGENDA
LEARNING POINTS
FROM REPORTED
INCIDENTS
PSU Update
We are pleased to inform you that the Patient Safety Update now includes data from
Scotland, expanding the opportunity to learn from patient safety incidents. The
summarised scenarios are real cases reported to have resulted in death or severe
harm in patients. The information provided can be sparse, which makes the
summaries short and often lacking an outcome. Postulating contributing factors can
be difficult. The more detail reported, the easier it is to identify problems and
recurring themes. The SBAR(1) tool may assist in providing a framework for the detail
of the event, as well as an initial assessment and analysis of the cause(s) and
contributing factors and indications of possible local recommendations for action.
SALG has used the SBAR tool in its guidance on Morbidity and Mortality presentations
(2).
Further Reading:
1 Thomas C. The SBAR Communication Technique. Nurse Educator 2009;34(4):176180.
2 Safe Anaesthesia Liaison Group. Anaesthesia Morbidity and Mortality Meetings: A Practical Toolkit for Improvement [Internet].
1st ed. 2013 [cited 22 May 2015]. Available from www.rcoa.ac.uk/node/14842
Balancing Risk
Incident Report:
Prescription and administration of Clexane to a patient only 2 hours after
neurosurgery.
Comments:
Ensuring that patients have their VTE risk assessed and managed is an
accepted part of the surgical safety checklist, and is part of the shared team
understanding. NICE(1) guidance on DVT prophylaxis in neurosurgery is scant
on timing, whilst the AAGBI(2) guidance on regional anaesthesia in patients
with coagulation abnormalities would suggest that LMWH prophylaxis should
be delayed for a minimum of 4 hours post op. Neurosurgery texts go further
and claim that delay for up to 24-48 hours post op minimises haematoma risks
without increasing DVT risk.
Further Reading:
1 Venous thromboembolism: reducing the risk. NICE 2010 [cited 19 May 2015].
Available from: www.nice.org.uk/guidance/cg92/chapter/1-recommendations#surgical-patients.
2 Cook T, Gill H, Hill D, Ingram M, Makris M, Malhotra S et al. Regional anaesthesia and patients with
abnormalities of coagulation [Internet]. 1st ed. Association of Anaesthetists of Great Britain and Ireland;
2013 [cited 19 May 2015]. Available from www.aagbi.org/sites/default/files/rapac_2013_web.pdf
3 Khaldi A1, Helo N, Schneck MJ, Origitano TC. Venous thromboembolism: deep venous thrombosis and
pulmonary embolism in a neurosurgical population. J Neurosurg 2011;114(1):40-46.
PATIENT SAFETY UPDATE JUNE 2015
Further Reading:
1 Vincent C, Taylor-Adams S. Systems Analysis of Clinical Incidents The London Protocol [Internet]. 1st
ed. London; [cited 22 May 2015]. Available from http://bit.ly/1IP9I0x.
2 Flin R, Patey R. Improving patient safety through training in non-technical skills. British Medical Journal
2009; 339:b3595.
3 Johnston MJ, Arora S, King D, Bouras G, Almoudaris AM, Davis R, Darzi A. A systematic review to identify
the factors that affect failure to rescue and escalation of care in surgery. Surgery 2015 Apr;157(4):752763.
4 Johnston MJ, Arora S, Pucher PH, Reissis Y, Hull L, Huddy JR, King D, Darzi A. Improving escalation of
care: Development and validation of the Quality of Information Transfer Tool. Ann Surg 2015 Mar 13.
PATIENT SAFETY
UPDATE
2015
[Epub
aheadJUNE
of print]
Drug Errors
Incident Report #1:
After induction of anaesthesia problems ventilating the patient reaction to
the anaesthesia resulting in brittle bronchospasm... started a salbutamol
infusion while investigating the cause. The cause turned out to be ventilator
failure rather than bronchospasm. The machine was replaced. Patient then
positioned but became tachycardic and hypotensive with ECG ST segment
changes could not explain this or connect it to the earlier events so stopped
the salbutamol and called for a second opinion. Several colleagues came to
help one colleague realised the miscalculation of salbutamol dose patient
received an overdose.
Incident Report #2:
Patient for emergency caesarean section. Accidental intravenous injection of
local anaesthetic. Immediately recognised. Treated with Intralipid as per AAGBI
Guidelines. Anaesthetised, baby delivered by emergency c/s uneventfully.
Mother remained haemodynamiclly stable.
Drug Errors
Comments:
In a crisis, making the diagnosis and delivering the correct treatment is difficult
and stressful. Crisis checklists help manage unfamiliar situations, e.g. acute
bronchospasm.(1) The AAGBIs Crisis Checklist Working party is developing
emergency checklists for local department adaptation.
Drug calculation errors are more common if you are stressed and also if using
an unfamiliar preparation. Many people find it helpful to use a two-person
check in this situation. NHS England and the MHRA released a stage three
directive on medication errors in April 2014. (2) The directive outlines the need
to strengthen clinical governance arrangements, to identify Medication Safety
Officers locally and to develop a medication safety network.
The latest never-events policy and framework document published on the 25
April 2015 now includes certain wrong route medication as a never-event.(2)
These include: intended intravenous chemotherapy delivered spinally,
intended enteral given parenterally and intended epidural given intravenously.
The NPSA (now NHS England) and the NRLS produced a guide to improve
safety with medicines entitled Safety in Doses which remains relevant today.
(3,4)
]
PATIENT SAFETY UPDATE JUNE 2015
Drug Errors
Further Reading:
1 Arriaga AF et al. Simulation based trial of surgical crisis checklists. N Engl J Med 2013; 368:246-253.
2 MHRA, NHS England. Patient Safety Alert: Improving medication error incident reporting and learning
[Internet]. March 2014 [cited 19 May 2015]. Available from: www.england.nhs.uk/wpcontent/uploads/2014/03/psa-sup-info-med-error.pdf
3 NHS England Patient Safety Domain. Revised Never Events Policy and Framework [Internet]. March
2015 [cited 19 May 2015].
Available from: www.england.nhs.uk/wp-content/uploads/2015/04/never-evnts-pol-framwrk-apr.pdf
4 National Patient Safety Agency and National Reporting and Learning Service. Safety in Doses
Improving the use of medicines
in the NHS [Internet]. August 2009 [cited 19 May 2015]. Available from:
www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.
axd?AssetID=61626&
Iatrogenic Injury
Incident Report #1:
Patient reported a hole in mouth after general anaesthesia (with LMA) for
knee arthroscopy... patient had a small (approx 5mm x 5mm) hole in the right
side of the soft palate had noticed a little blood in his mouth post op
apologised to the patient for the event and told him that review by the
maxillofacial team would take place advised that surgical repair under GA
was necessary. The anaesthetist responsible reported that on emergence in
the recovery area the patient has regurgitated a little and had required
suctioning with a Yankauer sucker. The patient had also developed
laryngospasm. The maxillofacial consultant felt that the most likely cause of
the trauma was from the Yankauer suction.
Incident Report #2:
Accidental iatrogenic intraoperative oesophageal perforation.
Iatrogenic Injury
Comments:
In the newsletter of the American Society of Anesthesiologists there is a report
on the latest review of closed claims looking at airway complications between
1980 and 2011. Airway injuries accounted for 9-11% of all closed claims in
each decade, and about one-third of all airway claims are associated with
difficult intubation. The oesophagus is the most common site of injury. (1)
A comprehensive summary of iatrogenic injury associated with anaesthesia is
available in the CEACCP. (2)
Further Reading:
1 Closed Claims Airway Injury Analysis Spotlights Problems [Internet]. 2015 [cited 22 May 2015].
Anesthesiology News www.anesthesiologynews.com/ViewArticle.aspx?
d=Clinical+Anesthesiology&d_id=1&i=April+2015&i_id=1168&a_id=30902
2 Contractor S, Hardman J. Injury during anaesthesia. CEACCP 2006;6(2):6770.
INCIDENT DATA
SUMMARY
Figure 1
Figure 2
Figure 2
shows the
type of
incidents
that
occurred
within the
anaesthetic
specialty
that were
reported
using LRMS
or the
anaesthetic
eForm for
the period 1
January 31
March 2015.
The
categories
were
determined
at local
level.
PATIENT SAFETY UPDATE JUNE 2015