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Showing results for tags 'Anaesthesia'.
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Content ArticleSafe and Sound is a podcast produced by the Barts Health Education Academy which aims to have honest, informative and educational discussions about patient safety and how it can be improved. In this episode, Dr Charlotte Hopkins, an HIV consultant who works in patient safety and Dr Annie Hunningher, a consultant anaesthetist and patient safety specialist, discuss the pros and cons between two different approaches to patient safety, Safety 1 and Safety 2.
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News Article
Coroner calls for allergies tsar after 17-year-old dies from anaesthetic reaction
Patient Safety Learning posted a news article in News
A senior coroner has warned that more allergy sufferers will die due to a “lack of national leadership” following the death of a 17-year-old aspiring doctor. Heidi Connor said the “tragic” case of Alexandra Briess was “not new territory”, citing three recent cases where people had died from anaphylaxis. She has now written to the Government saying lives are at risk without better funding and research into the condition and calling for the appointment of an allergies tsar. The Berkshire coroner’s warning comes after an inquest into the death of “bright and well loved” Alexandra, who died from a reaction to a common anaesthetic. Read full story (paywalled) Source: The Times, 18 April 2023 -
Content ArticleOn 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium. In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.
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Content ArticleIn this article for Chamber UK magazine, Lyn Brown MP warns that hysteroscopy could be the next big women's health scandal and calls for dramatic improvements in care. She describes the accounts of women being encouraged to undergo hysteroscopy without anaesthesia and appropriate pain relief, and how lack of informed consent is leaving women feeling violated and scared to undergo future gynaecological procedures. She also describes how she raised the issue in the House of Commons and outlines the failure of the Royal College of Obstetrics and Gynaecology's new 'Good Practice Paper' to properly address the decision making process and acknowledge the severity of the pain experienced by many women who undergo hysteroscopy. The article can be found on page 64 of the e-magazine.
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EventEnergy-based devices, lasers and diathermy are some of the most commonly used pieces of equipment in operating theatres today. Dangerous emissions can be produced that affect the respiratory systems of everyone in the operating theatre. This study day will look at the occupational hazards of exposure to surgical plume in the operating theatre, as well as the associated risks to the surgical team, patients and visitors. It will also highlight how to assess risk and mitigate against the dangers of surgical plume and how to implement changes. Topics Include: Electrosurgery/diathermy/laser. Anaesthetic airway fires. Laparoscopic surgery aerosolisation. Health and Safety and risk assessment. Surgical plume. Register
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Content ArticleThis correspondence published in Anaesthesia reflects on the recent guidance released by the Difficult Airway Society and the Association of Anaesthetists, 'Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals'. The authors highlight that although the guidance is a positive step forward in improving system safety in anaesthesia, there is a need to include a broader range of Human Factors (HF) specialists in the development of guidelines such as these. They call for a higher level of collaboration between clinicians and HF specialists to ensure that healthcare system safety can benefit from years of HF expertise.
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News Article
Scotland first country in the world to ban environmentally harmful anaesthetic
Patient Safety Learning posted a news article in News
Scotland has become the first country in the world to stop its hospitals using the anaesthetic desflurane because of the threat it poses to the environment. NHS data suggests the gas, used to keep people unconscious during surgery, has a global warming potential 2,500 times greater than carbon dioxide. Banning it in Scotland - from its peak use in 2017 - would cut emissions equal to powering 1,700 homes a year. In the last few years, more than 40 hospital trusts in England and a number of hospitals in Wales have stopped using it. Dr Kenneth Barker, anaesthetist and clinical lead for Scotland's national green theatres programme, said he was shocked to find the anaesthetic drug he had used for more than a decade for many major and routine operations was so harmful to the environment. "I realised in 2017 that the amount of desflurane we used in a typical day's work as an anaesthetist resulted in emissions equivalent to me driving 670 miles that day," he said. "I decided to stop using it straight away and many fellow anaesthetists have got on board. "When you are faced with something as obvious as this and with the significance it has to the environment - I am very glad we have got to this stage." Read full story Source: BBC News, 3 March 2023 -
Content ArticleIn this video, William Pileggi, a registered nurse anaesthetist, discusses the implementation of the Golden Eagle Project at the VA Pittsburgh Healthcare System to improve outcomes for veterans who may be prone to experiencing post-operative emergent delirium. Through assessments to prescreen for PTSD, staff training and using alternative drug therapies, his hospital has had zero injury events related to emergent delirium since 2018. With minor modifications, the program is replicable at civilian hospitals.
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Content Article
Hysteroscopy is a procedure used as a diagnostic tool to identify the cause of common issues such as abnormal bleeding, unexplained pain or unusually heavy periods. It involves a long, thin tube being passed through the vagina and cervix, into the womb, often with little or no anaesthesia. Studies indicate that some women do not find hysteroscopy procedures painful. However, it is now widely recognised that many women experience severely painful and traumatic hysteroscopies.[1-5] At Patient Safety Learning, we have worked with patients, campaigners, clinicians and researchers to understand the barriers to safe care and call for improvements.[6] We believe that no woman should have to endure extreme pain or trauma when accessing essential healthcare. In this blog we will: outline the key safety concerns around hysteroscopy procedures summarise recent national discussions highlighting these concerns reflect on the new national guidance outline six calls for action. -
Content ArticleThis editorial in Anaesthesia looks at how the term 'human factors' has been applied to different aspects of anaesthesia over the past few years. The author calls for a deeper look at the application of human factors in the field of anaesthesia to ensure systems are designed to minimise the risk of human error and variation.
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Content ArticleThese Guidelines for the Provision of Anaesthetic Services (GPAS) support the development and delivery of high quality anaesthetic services. GPAS chapters have previously focused on a particular aspect of clinical service delivery. However, experience has identified a requirement in GPAS to describe what it is about a department of anaesthesia itself, beyond the different aspects of the clinical service delivery, that contribute to a successful department. The Good Department chapter has been developed to address this requirement, describing current best practice for developing and managing a safe and high quality anaesthesia service in terms of the non-clinical aspects of the service that underpin the clinical provision. The guidance makes recommendations in terms of: leadership, strategy and management workforce education and training clinical governance support services.
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Content ArticleThe Association of Anaesthetists established a working group to help anaesthetics trainees with safe sleeping patterns. In this blog, Dr Emma Plunkett, consultant anaesthetist and chair of the working group, talks more about new initiatives to fight fatigue and why it’s important to monitor the impact of tiredness in the national training surveys.
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Content ArticleHealthcare relies on high levels of human performance; however, human performance varies and is recognised to fall in high-pressure situations, meaning that it is not a reliable method of ensuring safety. Other safety-critical industries embed human factors principles into all aspects of their organisations to improve safety and reduce reliance on exceptional human performance; there is potential to do the same in anaesthesia. This narrative review in the journal Anaesthesia aims to describe what is known about human factors in anaesthesia to date.
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Content ArticleThis consensus document by The Association of Anaesthetists of Great Britain & Ireland aims to improve patient safety. It is intended to act as a reference document for individuals and departments when considering the effects of hours of work and type of work undertaken in anaesthesia on clinician’s performance and wellbeing.
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Content ArticleThis study by a team at the University of Derby in the British Journal of Anaesthesia used experimental psychology methods to explore the potential benefits of colour-coded compartmentalised trays compared with conventional trays in a visual search task. The authors found that errors were detected faster when presented in the colour-coded compartmentalised trays than in conventional trays, a finding that was replicated for correct responses for error-absent trays. Overall, colour-coded compartmentalised trays were associated with significant performance improvements when compared with conventional trays.
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Content Article
This guidance on implementing human factors in anaesthesia has been produced by the Difficult Airway Society and the Association of Anaesthetists. 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. -
Content ArticleThe Royal College of Anaesthetists set up PatientsVoices@RCoA to help the College improve the delivery of safe, more effective, patient-centred care to enhance patients’ experience of anaesthesia and perioperative care. This plan by PatientsVoices@RCoA aims to set out a clear direction for our future work which ensures patients’ voices are clearly heard across all relevant activities, as the College delivers its strategic aims over the next five years.
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Content ArticleThis survey undertaken by SCATA and supported by the FightFatigue group is looking at rest facilities and culture in anaesthesia and intensive care. Aims: To describe the current situation regarding availability and quality of rest facilities in anaesthetic and intensive care departments in the UK and ROI, compared with current standards. To describe the current situation regarding rest culture in anaesthetic and intensive care departments in the UK and ROI, compared with current standards. To feedback to departments and provide a benchmarking of their practice as compared to current standards and peers nationally. If you would like to take part, please follow the link and enter the data into the data collection tool for each rota, in consultation with colleagues as you feel necessary. The data collected will be shared with partners in the FightFatigue group and used in line with the aims of the project as above and to produce a summary report. In this report, each Trust/Board will be able to identify their own data but not others. Please direct queries to fatigue@scata.org.uk.
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Content ArticleThis paper addresses information raised as part of a Delphi study of NHS hospital operating theatres in England. The aim of the first Delphi study round was to establish how the World Health Organisation’s Surgical Safety Checklist (SSC) is currently being used in the peri-operative setting as part of a strategy to reduce surgical ‘never events’. It used a combination of closed and open-ended questions that solicited specific information about current practice and research literature, that generated ideas and allowed participants freedom in their responses. The study asked theatre managers, matrons and clinical educators that work in operating theatres and deliver the surgical safety checklist daily, and who are therefore considered to be theatre safety experts. Participants were from the seven regions identified by NHS England. The study revealed that the majority of trusts don’t receive formal training on how to deliver the SSC, checklist champions are not always identified, feedback following a ‘never event’ is not usually given and that the debrief is the most common step missed. While the intention of the study was not to establish whether the lack of training, cyclical learning and missing steps has led to the increased presence of never events, it has facilitated a broader engagement in the literature, as well highlighting some possible reasons why compliance has not yet been universally achieved. Furthermore, the Delphi study is intended to be an exploratory approach that will inform a more in-depth doctoral research study aimed at improving patient safety in the operating theatre and informing policy making and quality improvement.
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Content ArticleWorldwide, most Caesarean sections (CS) are performed under neuraxial anaesthesia. However, neuraxial anaesthesia can fail and intraoperative breakthrough pain can occur. The aim of this study from Roofthooft et al. was to evaluate the incidence of breakthrough pain in consecutive CS and to describe the potential risk factors for breakthrough pain. In a two centre, prospective audit all CS performed under neuraxial anesthesia were included and the occurrence of breakthrough pain as well as all possible risk factors of breakthrough pain were recorded as well as the alternative anesthetic strategy.
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Content ArticleIn this letter, campaign group Hysteroscopy Action, have written to Women’s Minister, Maria Caulfield, to raise its concerns about the levels of pain and trauma experienced by many women undergoing outpatient hysteroscopy procedures. The letter, which has over 20 signatories, including Helen Hughes, Chief Executive of the Patient Safety Learning charity. It calls for more theatre space for women to have procedures under general anaesthetic as well as offering women the choice of intravenous sedation. Related reading Horror as women are facing major medical procedures without anaesthetic, warn experts Guidance for outpatient hysteroscopy: Consultation Response (Patient Safety Learning) Patient experiences shared with us in our community thread Pain during ambulatory hysteroscopy: A presentation by Richard Harrison (3 minute video) 2020: Raising awareness about painful hysteroscopies (8 minute video) Pain-free day surgery? Evaluating pain and pain assessment during hysteroscopy Ministers respond to concerns about painful hysteroscopies: Northern Ireland, Scotland and Wales Read the letter to Maria Caulfield in full below.
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EventuntilThis ASCEND (acquiring skills, career exploration, networking and development) webinar aims to help students and newly qualified practitioners to develop the practical and personal skills needed to succeed during the early years of their perioperative career. It will focus on two main skills - leadership and the management of anaesthetic emergencies. Leadership is often mistaken for something that only comes with vast experience in a particular discipline. We will be re-examining ‘what is leadership?’ and introducing some leadership opportunities available early in your perioperative career. Management of anaesthetic emergencies is a crucial part of perioperative care. This is not only relevant for anaesthetic practitioners, it incorporates the whole theatre team. Being able to identify an anaesthetic emergency is a valuable skill in your early career. Learning outcomes: An introduction into leadership opportunities available early in your perioperative career. Understand different styles of leadership and how you can deploy them in your everyday practice. Identifying anaesthetic emergencies and learning through virtual simulation. Register
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Content ArticleAre you applying Safety-II principles to improve safety in maternity, A&E, ICU or anaesthetics? If so, Dr Ruth Baxter would love to interview you!
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EventuntilThe Safe Anaesthesia Liaison Group Patient Safety Conference will be held in collaboration with RA-UK. The first session will include engaging lectures around the current work of SALG, and the second session will focus on topical issues in relation to regional anaesthesia safety. There will be a prize session for accepted abstracts, with a poster section and oral presentations. This online conference is being organised by SALG co-chairs, Dr Peter Young from the Association of Anaesthetists, Dr Felicity Platt, Royal College of Anaesthetists and Nat Haslam, Regional Anaesthesia UK The day will provide valuable knowledge for doctors engaged in clinical anaesthesia, pain management and intensive care medicine, and who have an interest in improving patient safety. Register
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Content ArticleThis article in the Anesthesia Patient Safety Foundation newsletter looks at the issues surrounding the contribution of anaesthetic gasses to healthcare pollution and emissions. The authors argue that the next patient safety movement should be sustainable healthcare. They highlight that anaesthetists have the opportunity to lead in the effort to reduce healthcare’s impact on population health, and demonstrate to the wider sector that sustainable healthcare is possible and important to the wellbeing of patients.
