More than a dozen NHS patients have stopped breathing and 40 others suffered serious effects after having powerful anaesthetic drugs mistakenly “flushed” into their systems by unsuspecting NHS staff.
In one case a man has been left suffering nightmares and flashbacks after he stopped breathing on a ward when a powerful muscle relaxant used during an earlier procedure paralysed him but left him fully conscious. He only survived because a doctor was on the ward and started mechanically breathing for him.
An investigation by the safety watchdog, the Healthcare Safety Investigation Branch (HSIB), found there had been 58 similar incidents in England during a three-year period.
The mistakes happen when residual amounts of drugs are left in intravenous lines and cannulas and not “flushed” out after the surgery. When the IV lines are used later by other staff the residual drugs can have a debilitating effect on patients.
In a new report HSIB said flushing intravenous lines to remove powerful drugs was a “safety-critical” task but that the process for checking this had been done was not being properly carried out, posing a life-threatening risk to patients.
It said the use of a checklist by anaesthetic staff can be overlooked when doctors are busy with other tasks and they fail to engage with the process.
Source: The Independent, 4 March 2021