NHS England case study: Anaesthetic vapour delivered inadvertently

Summary

This NHS England case study is one in a set of patient safety ‘how we acted on patient safety issues you recorded’ case studies which show the direct action taken in response to patient safety events recorded by organisations, staff and the public, and how their actions support the NHS to protect patients from harm.

Content

Through its core work to review recorded patient safety events the National Patient Safety Team identified a risk of inadvertent exposure to anaesthetic agent.

An incident report described a patient being given an unintended dose of the inhaled anaesthetic agent isoflurane, after the vaporiser (a device attached to an anaesthetic machine which delivers the anaesthetic) had been left on. The patient was being given oxygen via an anaesthetic machine during their immediate post operative recovery period. The patient recovered.

A search of the National Reporting and Learning System (NRLS) over a two-year period identified nine similar incidents in which patients were inadvertently administered a dose of anaesthetic agent due to a vaporiser being left on.

The issue was shared with the Medicines and Healthcare products Regulatory Agency (MHRA) and the Safe Anaesthesia Liaison Group (SALG), so they could promptly review the design of vaporisers used to deliver anaesthetics, to make it clearer to staff if they are on or off. SALG agreed to this issue being considered by the Association of Anaesthetists ‘Anaesthesia Equipment Standards Committee’. 

The issue was also communicated to the network of Medical Device Safety Officers across NHS providers, to encourage them to report any similar incidents to the MHRA’s Yellow Card reporting system to support further learning around the issue.