Top picks: 12 resources on anaesthesia safety

Summary

Anaesthetic techniques and equipment have greatly improved over the last 60 years, as has the training and safety equipment to protect patients. If you are in good health modern anaesthetics are really very safe. However, all procedures have some risks and it is important that patients are fully informed and that the anaesthetist discusses the procedure and the risks with the patient, taking into account the patient's medical history.

At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples.

We have pulled together 12 useful resources about anaesthesia that have been shared on the hub. They include insights from anaesthetists and examples of good practice.

Content

1 Patient Safety Spotlight interview with Annie Hunningher, Consultant Anaesthetist at the Royal London Hospital, Barts Health

In this interview, Annie talks to us about her work training teams in safety behaviours, why productivity and safety must go hand-in-hand, and how working on patient safety is like running a marathon.

2 Modeling anesthesia medication delivery using the SEIPS 101 tool

SEIPS 101 tools provide a series of practice-orientated techniques to apply systems model in real clinical practice, potentially offering a straightforward approach to mapping perioperative medication delivery systems. Data was collected during direct observations of thirty-eight anaesthetics, totalling over 100 h on anaesthesia providers’ common tasks and interactions with people, environments, tools, and technologies. Observation data, notes, interviews, and literature were organised to create six SEIPS 101 tools demonstrating the complexity of anaesthesia medication delivery.

3 Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals

Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies.

4 Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UK

Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), shares a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.

5 Hysteroscopy pain: A discussion with anaesthetists. A blog by Helen Hughes

In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists.

6 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff

Sam Goodhand is a registrar in the Sussex region, specialising in anaesthetics and intensive care medicine. In this interview for Patient Safety Learning he tells us how and why he developed an accessible checklist for staff involved in intubation processes. 

7 Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists

These guidelines from the Association of Anaesthetists aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors.

8 RCOA infographic - Common events and risks for children and young people having a general anaesthetic

This infographic by the Royal College of Anaesthetists shows some of the common events and risks that healthy children and young people of normal weight face when having a general anaesthetic (GA) for routine surgery. It highlights that modern anaesthetics are very safe and that most common side effects are usually not serious or long lasting. It also outlines the conversations children and their families should expect to have with their anaesthetist prior to their procedure.

9 Association of Anaesthetists case reports: Invaluable learning from mistakes

In this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps.

10 The normalisation of patient care: Developing global guidance on securing an airway

In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia. 

11 Keeping patients safe during emergency tracheostomy management

A tracheostomy is a common procedure done for patients who need prolonged mechanical ventilation, are unable to protect their airway or have pathologies of the oropharynx leading to the potential for upper airway obstruction. While a tracheostomy is relatively safe, complications are common, and it is essential to understand the management steps to ensure that the patient’s tracheostomy functions as intended. This article in the Anaesthesia Patient Safety Foundation newsletter discusses how to keep patients safe during emergency tracheostomy management.

12 Improving hand hygiene in the anesthesia workspace: The importance, opportunities, and obstacles

Anaesthesia professionals have consistently been leaders in patient safety and have long recognised the importance of hand hygiene in the anaesthesia workspace. Hand contamination is associated with pathogen transmission across multiple anaesthesia workspace reservoirs, and genome analysis of bacteria cultured from provider hands and infection causing pathogens have confirmed that providers transmit pathogens that result in patient infections. Staphylococcus aureus (S. aureus) transmission among anaesthesia workspace reservoirs is associated with an increased risk of surgical site infection (SSI). In order to reduce this risk, a multifaceted approach is needed to prevent SSIs. 

Do you have a resource or story about anaesthesia to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.