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Showing results for tags 'Anaesthesia'.
Found 146 results
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News Article
Family welcomes new guidance to prevent breathing tube deaths
Patient Safety Learning posted a news article in News
A grieving family has welcomed new guidance to try to prevent a common surgical procedure from going wrong and causing deaths. Oesophageal intubation occurs when a breathing tube is placed into the oesophagus, the tube leading to the stomach, instead of the trachea, the tube leading to the windpipe. It can lead to brain damage or death if not spotted promptly. Glenda Logsdail died at Milton Keynes University Hospital in 2020 after a breathing tube was accidentally inserted into her oesophagus. The 60-year-old radiographer was being prepared for an appendicitis operation when the error occurred. Her family welcomed the guidance, saying in a statement: “We miss her terribly but we know that she’d be happy that something good will come from her tragic death and that nobody else will go through what we’ve had to go through as a family." Oesophageal intubation can occur for a number of reasons including technical difficulties, clinician inexperience, movement of the tube or “distorted anatomy”. The mistake is relatively common but usually detected quickly with no resulting harm. The new guidance, published in the journal Anaesthesia, recommends that exhaled carbon dioxide monitoring and pulse oximetry – which measures oxygen levels in the blood – should be available and used for all procedures that require a breathing tube. Experts from the UK and Australia also recommended the use of a video-laryngoscope – an intubation device fitted with a video camera to improve the view – when a breathing tube is being inserted. Read full story Source: The Independent,18 August 2022 -
Content ArticleAcross multiple disciplines undertaking airway management globally, preventable episodes of unrecognised oesophageal intubation result in profound hypoxaemia, brain injury and death. These events occur in the hands of both inexperienced and experienced practitioners. Current evidence shows that unrecognised oesophageal intubation occurs sufficiently frequently to be a major concern and to merit a co-ordinated approach to address it. Harm from unrecognised oesophageal intubation is avoidable through reducing the rate of oesophageal intubation, combined with prompt detection and immediate action when it occurs. These guidelines provide recommendations for preventing unrecognised oesophageal intubation that are relevant to all airway practitioners independent of geography, clinical location, discipline or patient type.
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Content ArticleIn this letter to the Guardian newspaper, a specialist nurse writes on an NHS service that puts women in control of pain relief, Sara Davies on the torturous pain she endured to have an intrauterine device fitted, and Lee Bennett on why it pays to speak up persistently. Have you experienced pain during a medical procedure? Share your experience along with hundreds of women to one of our community forums: Do women experience poorer medical attention when it comes to pain? Pain during IUD fitting Painful hysteroscopy
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News Article
Staff shortages leaving women in ‘barbaric’ pain
Patient Safety Learning posted a news article in News
Patient safety campaigners have said ‘too many women’ are still not being offered a general anaesthetic for a diagnostic test because of staff shortages, leaving them in severe pain. A survey by the Campaign Against Painful Hysteroscopies found around 240 women – which equates to 80 per cent of respondents – who had a hysteroscopy since the start of 2021 said they were not told they could have a general anaesthetic prior to the procedure. This suggests the situation has only improved marginally since 2019, when the campaign group first started collecting data. A spokeswoman from the campaign group called the pain being endured by women “barbaric” and said staffing shortages need to be addressed. Guidance from the Royal College of Obstetricians and Gynaecologists said all pain relief options, including general anaesthetic, should be discussed. Helen Hughes, chief executive of Patient Safety Learning, said: “We are hearing from too many women that they are not being given the full information about the procedure. It damages their trust and makes them worry about accessing future services.” She said: “It’s distressing that despite what we know, [the guidance] is not being implemented properly. Informed consent is essential for patient safety as well as a legal requirement.” Read full story (paywalled) Source: HSJ, 7 June 2022 What is your experience of having a hysteroscopy? Share your experiences on the hub in our community forum. Further reading: House of Commons Debate - NHS Hysteroscopy Treatment Through the hysteroscope: Reflections of a gynaecologist Minister acknowledges patients’ concerns about painful hysteroscopies; but will action be taken? Improving hysteroscopy safety: Patient Safety Learning blog Outpatient hysteroscopy: RCOG patient leaflet- Posted
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News ArticleWomen undergoing NHS operations are not being routinely informed that a drug commonly used in anaesthesia may make their contraception less effective, putting them at risk of an unplanned pregnancy, doctors have warned. Administered at the end of surgery before patients wake up, sugammadex reverses the action of drugs that are given earlier in the procedure to relax the patient’s muscles. The drug is known to interact with the hormone progesterone and may reduce the effectiveness of hormonal contraceptives, including the progesterone-only pill, combined pill, vaginal rings, implants and intra-uterine devices. However, new research suggests that robust methods for identifying at-risk patients and informing them of the associated risk of contraceptive failures is not common practice across anaesthetic departments in the UK. Current guidance says doctors must inform women of child-bearing age about the drug. Women taking oral hormonal contraceptives should be advised to follow the missed pill advice in the leaflet that comes with their contraceptives, and those using other types of hormonal contraceptive should be advised to use an additional non-hormonal means of contraception for seven days. But doctors at a major London hospital trust found no record within the medical notes of relevant patients that they had been given advice on the risks of contraceptive failure due to sugammadex. Read full story Source: The Guardian, 2 June 2022
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Content ArticleThis 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.
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EventuntilThe perioperative environment is complex and rapidly changing with a diverse, multi-professional workforce. A global shortage of perioperative practitioners has forced us to ‘bridge the gap’ by working collaboratively across many boundaries and specialities to deliver safe, high-quality patient care. This study day from the Association for Perioperative Practice (AfPP) explores how embracing a multi-professional approach to perioperative care can help us to build theatre teams that are fit for the future. From Anaesthetists to Registered Operating Department Practitioners (RODPs) and Registered Nurses (RNs), there are many transferable skills across perioperative professions. Our speakers will identify some of these transferable skills, explore the lessons we can learn from our multi-disciplinary colleagues, and examine four key areas of practice. The goal is to provide you with evidence-based practice that can be taken back to your workplace to further educate the multi-professional team and facilitate changes in practice to improve patient safety and reduce never events. Topics include: Lessons learnt as a consultant anaesthetist. Potential barriers to preventing harm. Recognising and managing difficult airways. Inadvertent hyperthermia prevention and management. ‘Not Just Small Adults’ – paediatric perioperative care. Safe manual handling and patient positioning. Transferrable skills – from RODP to management. Register
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Content ArticleA woman who experiences pain during caesarean section under neuraxial anaesthesia is at risk of adverse psychological sequelae. Litigation arising from pain during caesarean section under neuraxial anaesthesia has replaced accidental awareness under general anaesthesia as the most common successful medicolegal claim against obstetric anaesthetists. Generic guidelines on caesarean section exist, but they do not provide specific recommendations for this area of anaesthetic practice. This guidance aims to offer pragmatic advice to support anaesthetists in caring for women during caesarean section. It emphasises the importance of non-technical skills, offers advice on best practice and aims to encourage standardisation. The guidance results from a collaborative effort by anaesthetists, psychologists and patients and has been developed to support clinicians and promote standardisation of practice in this area.
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Content Article
The IPP (Innovation, People and Practice) magazine
Patient Safety Learning posted an article in Surgery
Published 10 times a year by the Association for Perioperative Practice, the IPP covers a variety of topics relevant for perioperative practitioners. Ranging from news and information, special focus pieces, industry interviews and profiles of company leaders in an easy-to-read format. -
Content ArticleThis webpage contains information from the Royal College of Anaesthetists (RCOA) on coroners' reports that have been sent to the RCOA so that action can be taken to prevent future deaths. The webpage contains: information about the latest reports received. links to articles relating to the patient safety issues identified. information on multidisciplinary team training. training videos.
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Content ArticleSedation for therapeutic and investigative procedures in healthcare is extensively and increasingly used. In 2013 the Academy of Medical Royal Colleges (the Academy) published Safe sedation practice for healthcare procedures: Standards and guidance (this updated and replaced earlier guidance). The guidance recommended core knowledge, skills and competencies required for the safe delivery of effective sedation. It also highlighted that safety will be enhanced by the provision of achievable standards, along with the availability of appropriate facilities and monitoring used under good organisational governance of staffing, equipment, education and practice. However, despite this, avoidable morbidity and mortality continue to occur. Service reviews by the Royal College of Anaesthetists’ (RCoA’s) Anaesthesia Clinical Services Accreditation (ACSA) programme suggest that the recommendations in the 2013 guidance have not been fully acted upon by many hospitals. Therefore, this update summarises the recommendations to provide regulators with a set of standards against which to inspect facilities providing sedation and to ensure that safety standards are being met.
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Content ArticleThis article explains some of the background to the new national standardised operating procedure to prevent wrong side block, developed by a working party of the Safe Anaesthesia Liaison Group (SALG). However, the document may seem a little unusual, since it is not presented as a barrier to wrong side block. Rather, its main aim is to standardise practice across hospitals so that any future events can be analysed against a common framework; hence the designation as a standardised operating procedure and not a guideline. As a result the incidence of wrong side blocks will diminish, but not be eliminated. ‘Prep, stop, block’ describes the process to be followed; enhancing the message of ‘stop before you block’ that the stop moment should occur just before needle insertion.
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News Article
Coroner concerned with Barts NHS trust after woman 'unlawfully killed'
Patient Safety Learning posted a news article in News
Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure. He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point. Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient." Read full story Source: Newham Recorder, 17 January 2022 -
Content ArticleSurekha Shivalkar was a 78-year-old woman who was scheduled for elective total hip replacement revision surgery. Following surgery she suffered a cardiac arrest and subsequently died. The conclusion of the inquest was that died from multi-organ failure and complications arising during anaesthesia and hip revision surgery, which led to hypotension and hypoperfusion in a woman with ischaemic heart and chronic obstructive pulmonary disease. In his report, the Coroner raises concerns about the lack of a use of a formal risk assessment tool prior to her surgery, communication failures between the orthopaedic surgical team and the anaesthetist and the departure of the Senior Consultant surgeon prior to the surgeries conclusion.
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Content ArticleThis article, published in the British Journal of Anaesthesia, explores how medication-related adverse events in anaesthesia care are frequent and require a deeper understanding if medication harm is to be prevented. The study looked at a Spanish incident report database over a ten-year period to conclude that harm could have been mitigated.
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Content ArticleThis article, published in Best Practice & Research Clinical Anaesthesiology, looks at the importance of Incident Reporting Systems in improving patient safety and how they can be better used to have an improved impact.
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Content ArticleThe Royal College of Anaesthetists is launching a campaign to prevent future deaths from unrecognised oesophageal intubation following a recently received coroner’s report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. The coroner’s report highlighted the critical importance of human factors in safe anaesthetic practice. In this blog, Matt Bigwood and Chris Frerk discuss how one of the main aims of the campaign is to empower every team member, regardless of position, to be able to speak up if they spot this problem. You can also read more about the campaign here.
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Content ArticleThe Royal College of Anaesthetists recently received a coroners report where an oesophageal intubation took place and was not recognised in time to save the life of the patient. Unrecognised oesophageal intubation is preventable through adherence to published recommendations on the monitoring of exhaled carbon dioxide (capnography) and its correct interpretation. All clinicians involved in airway management should watch the College and DAS video on capnography. Always remember 'No Trace = Wrong Place' and actively seek to exclude oesophageal intubation when a flat capnograph trace is encountered.
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Content ArticleIn 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. The authors also examine the impact that learning projects based on incident reporting can have on clinicians involved in the initial incidents, highlighting that revisiting errors may prevent individuals from moving on from them.
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Content ArticleThis study in Anaesthesia reviewed accidental spinal administration of tranexamic acid. The review identified 20 cases of accidental administration resulting in life-threatening neurological or cardiac complications and 10 patient deaths. These cases were analysed using a Human Factors Analysis System Classification model to identify contributing factors. Ampoule error was the cause in 20 incidents, and all were classified as skills-based errors. Organisational policy, storage of medication and preparation for anaesthesia were all identified as contributing factors. The authors concluded that all of these events could have been avoided if four published recommendations for the prevention of spinal medication administration were implemented.
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Content ArticleIn this article in the Anesthesia Patient Safety Foundation Newsletter, Katsuyuki Miyasaka talks about the history of the pulse oximeter in Japan and celebrates one of it's earliest developers, Takuo Aoyagi. The author recognises the life-saving impact of pulse oximeters, but talks about the need for more education and regulation around the use of this readily available device. Miyasaka highlights that the quality of devices is variable and that when patients attempt to interpret the numbers they see, it may lead to harm.
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Content ArticleThe Anesthesia Patient Safety Foundation Newsletter is the official publication of the non-profit Anesthesia Patient Safety Foundation and is published three times per year in Wilmington, Delaware, USA. Download all copies of the newsletter
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Content ArticleGetting It Right First Time (GIRFT) is designed to improve the quality of care within the NHS by reducing unwarranted variations. By tackling variations in the way services are delivered across the NHS, and by sharing best practice between trusts, GIRFT identifies changes that will help improve care and patient outcomes, as well as delivering efficiencies such as the reduction of unnecessary procedures and cost savings.
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Content ArticleThis article by Robin Aldwinckle discusses the case study of a 61-year-old male patient with severe knee osteoarthritis and hypertension who was admitted for surgery under subarachnoid regional anesthesia. However at the end of the procedure, the patient remained unresponsive and was subsequently diagnosed with Local Anesthetic Systemic Toxicity (LAST). Whilst the patient recovered, this case highlights a lack of communication between the operating room team members concerning the safe dosing of local anesthetics and that the correct diagnosis and treatment of LAST in the operating room is critically important.
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Content Article
Perioperative approach of allergic patients
Patient-Safety-Learning posted an article in Allergies
This research article focuses on the patient safety aspects of handling and recognising allergic reactions and severe perioperative anaphylaxis, and discusses the basic approach of the allergic patient and of patients with a suspected allergy to perioperatively administered medication.
