Search the hub
Showing results for tags 'Anaesthesia'.
Found 146 results
-
Content ArticleThis article on sex and gender differences discusses the definitions, general and perioperative implications and how acknowledging differences between men and women relevant to anesthesia is of paramount importance to ensuring perioperative patient safety.
-
Content Article
When a patient can’t breathe by themselves, healthcare staff may decide to intubate them to make it easier to get air into and out of the lungs. A tube goes down the throat and into the windpipe, and a machine called a ventilator pumps in air with extra oxygen. It can be life-saving, but life-threatening complications can also occur during a significant number of these procedures. 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. -
Content ArticleThis report describes the impact of patient adverse events and near misses, including their use of incident reporting systems and the organisational support available.
-
Content ArticleThis article describes the application of colour coding for cognitive aids to facilitate the management of an unanticipated difficult airway and its further local implementation in the form of a colour-coded difficult airway trolley. The authors conclude that the use of colour coding as a cognitive aid can enhance the management of an unanticipated difficult airway and make it simpler to obtain help from other operating room personnel who are not regularly involved in airway management. However, they note that frequent training and simulation with the material and equipment in the difficult airway trolley remains crucial.
-
Content ArticleImproving patient safety during anesthesia and surgery is a major public health issue, with safety standards varying from country to country. Anesthesia safety is often hampered by complex problems in low income countries. This survey assesses the unmet anesthesia needs in Ethiopia. The author concludes that anesthesia safety in Ethiopia appears challenged by substandard continuous medical education and continuous professional development practice, and limited availability of some essential equipment and medications. The study states that while patient monitoring and anesthesia conduct are relatively good, World Health Organization surgical safety checklist application and postoperative pain management are very low, affecting the delivery of safe anesthesia conduct.
-
Content Article
Op-Ed: Surgery is forever changed by COVID (April 2021)
PatientSafetyLearning Team posted an article in Surgery
During the COVID-19 pandemic, health systems and providers scaled back non-emergency care, including cancelling non-urgent surgeries during the COVID-19. While this cautious approach was necessary early in the pandemic, it limited health systems' and providers' ability to fulfil their mission and deliver needed care to patients. In this article, published by Medpage Today, Beverly Philip, looks at how looks at how we can find a safe way forward. -
News ArticleMore 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. Read full story Source: The Independent, 4 March 2021
-
Content ArticleThis Healthcare Safety Investigation Branch (HSIB) investigation looked at the risks to patients when intravenous (IV) drugs are retained in cannulae and extension lines. Some drugs, such as those used in anaesthesia and pain management, can cause patients to stop breathing. After administration, these drugs should be flushed through cannulae and extension lines to make sure no residual quantities of the drugs are left. Despite the issuing of multiple safety alerts over the past ten years, residual drugs in cannulae and extension line events continue to happen. When these events involve drugs that cause the patient to stop breathing, there is a risk of hypoxic brain injury (where the brain is damaged after a period where it does not get enough oxygen) or death. The investigation was launched after concerns were reported to HSIB by a consultant anaesthetist at a district general hospital where a patient had stopped breathing several hours after undergoing an anaesthetic. It’s thought that a quantity of the drug Suxamethonium - a muscle relaxant - was retained in their cannula after the procedure. The cannula containing the drug was flushed on the ward by a nurse preparing to administer intravenous paracetamol around three hours after the patient had returned from his procedure. The event was witnessed by a doctor who immediately started manual ventilation. The patient began to breathe spontaneously a few minutes later and suffered no physical harm. However, they have been left with a significant psychological impact following their experience of being awake but unable to move or breathe.
-
Content Article
OrphanAnesthesia: Patient Safety Card
Patient Safety Learning posted an article in Rare diseases
OrphanAnesthesia offers a Patient Safety Card for all hospitals, patients, and support groups. The patient or the physician fills in the name of the rare disease to notify the anaesthesiologist/ emergency personnel of the rare disease, and of the recommendation for the anaesthetic management. The card should be given to the anaesthesiologist before anaesthesia. It should be carried by the holder in case of emergency. The OrphanAnaesthesia website is indicated on the card for further information. -
Content ArticleGeneral anaesthesia for obstetric surgery has distinct characteristics that may contribute towards a higher risk of accidental awareness during general anaesthesia. The primary aim of this study from Odor et al. was to investigate the incidence, experience and psychological implications of unintended conscious awareness during general anaesthesia in obstetric patients. Researchers discovered that one in 256 women going through pregnancy-related surgery are aware of what was going on — a far higher proportion than the one in every 19,000 identified in a previous national audit. If a patient is conscious at some point while under general anaesthetic, they may be able to recall events from the surgery such as pain or the sensation of being trapped, the researchers said.
-
News ArticleMore women may suffer pain due to being conscious while undergoing caesareans or other pregnancy-related surgery under general anaesthetic than realised, a troubling new study has found. The report, conducted by medical journal Anaesthesia, found being awake while having a caesarean is far more common than it is with other types of surgery. Researchers discovered that one in 256 women going through pregnancy-related surgery are aware of what was going on — a far higher proportion than the one in every 19,000 identified in a previous national audit. If a patient is conscious at some point while under general anaesthetic, they may be able to recall events from the surgery such as pain or the sensation of being trapped, the researchers said. While the experiences generally only last for a few seconds or minutes, anaesthetists remain highly concerned. Women also felt tugging, stitching, feelings of dissociation and not being able to breathe - with some suffering long-term psychological damage that often involved characteristics of post-traumatic stress disorder. Read full story Source: The Independent, 13 January 2021
-
Content Article
Safer Anaesthesia From Education (SAFE)
Patient Safety Learning posted an article in In surgery
Safer Anaesthesia From Education (SAFE) is a joint project developed in 2011 by the Association of Anaesthetists and the WFSA (World Federation of Societies of Anaesthesiologists). The training initiative aims to bring practitioners of obstetric and paediatric anaesthesia (who throughout the world may be physician anaesthesiologists but are largely non-physicians) to a level of practice whereby they can deliver vigilant, competent, and safe anaesthesia. The underlying principle is to equip anaesthetists with the essential knowledge and skills so they can deliver safe care to their patients, even in very low resource settings, and to train as many anaesthesia providers as possible in each country in order to create a sustainable training model which can be embedded in the national health system. -
Content Article
WHO: Anaesthesia safety checklist
Patient Safety Learning posted an article in Surgery
Anaesthesia safety checklist from the World Health Organization (WHO) covering: before induction of anaesthesia operating room operative procedure list postoperative care. -
Content ArticleFor some people, anaesthesia is one of the scariest parts of surgery. Do you wonder about the risks, too? Anesthesiologist Christopher Troianos offers some insights to help separate fact from fiction. He highlights five key points about anesthesia that are sometimes misunderstood or have changed in recent years.
-
News ArticleWomen are undergoing “painful and distressing” diagnostic tests as doctors use the COVID-19 pandemic as an excuse not to offer them their choice of pain relief, HSJ has been told. At least 70 women who have had hysteroscopies this year in English NHS hospitals said they were left in extreme pain following the procedures, with many suffering trauma for several days, according to a survey by the Campaign Against Painful Hysteroscopies group. Some women claimed doctors used COVID-19 as an “excuse” not to offer sedation or general anaesthetic. Others said they were offered an inpatient appointment with general anaesthetic, but were also told it would be a long wait and would likely be cancelled due to covid pressures. Women also said they were told an outpatient procedure would reduce the time spent in hospital and consequently reduce the risk of contracting covid. The only pain relief on offer was often just ibuprofen and some women said facilities like recovery rooms were unavailable. The vast majority of the women surveyed — more than 90% — said they were traumatised for a day or longer by the pain from the procedure, A RCOG spokeswoman said: “We are concerned to hear that women are going through painful and distressing hysteroscopy procedures and that they feel COVID-19 is being used as an excuse not to offer a choice of anaesthetic." “The covid-19 pandemic has put incredible strain on the health services, and the risk of transmission of the virus has meant they’ve had to adapt their procedures. Whilst all women should be offered a choice of anaesthesia and treatment settings for hysteroscopic procedures, an outpatient setting avoids hospital admission and reduces the risk of exposure to the virus." “The RCOG guidance on this is very clear — all pain relief options should be discussed with women, as well as the risks and benefits of each. Women should be given the choice of a local or general anaesthetic. If the procedure is still too painful, no matter what anaesthetic options are chosen, it must be stopped and a further discussion of pain relief options should then take place. It’s vital that women are listened to and their choice is fully supported.” Read full story Source: HSJ, 21 December 2020
-
EventDr Donna Prosser, Chief Clinical Officer at the Patient Safety Movement Foundation, is joined by a group of experts, including pharmacists, anesthesiologists, respiratory therapists, family members, and nursing leaders, to explore the patient safety priorities of sedation, opioid therapy and respiratory depression. The group will discuss frequently encountered safety issues, explore organisational processes to reduce sedation safety events, and assess the role patients and family members can play in reducing harm. Register
-
Content ArticleThis month, we’ve been looking back over 2020 and highlighting some of the key areas of health and care that Patient Safety Learning has worked in this year. First, Chief Executive, Helen Hughes, gave an overview, detailing some of the main ways we’ve been achieving our aims as an organisation. Following that, we looked at the impact of the COVID-19 pandemic on patient safety, and, earlier this week, we focused on advice and support for people living with Long COVID. In this blog, Patient Safety Learning reflect on the work we’ve been doing to highlight serious patient safety concerns relating to hysteroscopy procedures in the NHS and how we’ve been making the case for change.
-
Content ArticleToday was the Parliamentary launch event of the Surgical Fires Expert Working Group’s report, 'A case for the prevention and management of surgical fires in the UK', which focuses on the prevention of surgical fires in the NHS This report contains important information on surgical fires and their prevention, to be submitted to the Centre for Perioperative Care (CPOC), in order to make the case for its inclusion on their agenda. In the perioperative setting, a fire may cause injury to both the patient and healthcare professionals. Injuries caused by a surgical fire most commonly occur on the head, face, neck and upper chest. The prevention of surgical fires, which can occur on or in a patient while in the operating theatre, is an urgent and serious patient safety issue in UK hospitals. A Short Life Working Group (SLWG) for the prevention of surgical fires was established in May 2019, following an initial discussion in December 2018 on the issue of surgical fires in the UK. The group of experts from healthcare organisations and bodies across the UK convened four times in 2019 with the aim of compiling this document, in order to recommend surgical fires for a Never Event classification. The group conducted a literature review of best practice and evidence, in the UK and internationally, which informed the development of a number of considerations that could address the issue of surgical fires. This report contains information surrounding the scale of the problem of surgical fires in the UK, in addition to reported experiences of these incidences by both healthcare professionals and patients. It also includes prevention and management materials, and mandatory training that should be consistently delivered to hospital staff, and concludes with recommendations moving forward, in order to ensure the prevention of surgical fires in UK hospitals.
-
Content Article
Patient Safety Authority: Surgical fires
Patient Safety Learning posted an article in Surgery
Fires on the operating field are rare events that should never happen, but do. They are dangerous not only to the patient but to the operating room (OR) team members as well. Surgical fires remain a significant enough risk to justify use of a Fire Risk Assessment Score and adherence to the recommendations of the American Society of Anesthesiologists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation. Here, the Pennsylvania Patient Safety Authority shares key data and statistics, educational tools, multimedia and related links on surgical fires. -
Content ArticlePatient safety is an activity to mitigate preventable patient harm that may occur during the delivery of medical care. The European Board of Anaesthesiology (EBA)/European Union of Medical Specialists had previously published safety recommendations on minimal monitoring and postanaesthesia care, but with the growing public and professional interest it was decided to produce a much more encompassing document. The EBA and the European Society of Anaesthesiology (ESA) published a consensus on what needs to be done/achieved for improvement of peri-operative patient safety. During the Euroanaesthesia meeting in Helsinki/Finland in 2010, this vision was presented to anaesthesiologists, patients, industry and others involved in health care as the ‘Helsinki Declaration on Patient Safety in Anaesthesiology’. Authors of this article, published in the European Journal of Anaesthesiology, hope to further stimulate implementation of the Helsinki Declaration on Patient Safety in Anaesthesiology, as well as initiating relevant research in the future.
-
Content ArticleSusan Warby, 57, was mistakenly given a glucose rather than a saline drip at West Suffolk Hospital after an operation for a perforated bowel in July 2018. Staff noticed a rise in blood sugar concentrations but gave her insulin to lower them rather than check the drip, which remained in place for 36 hours. In 2008 the National Patient Safety Agency made recommendations for safe arterial line management. In 2014 the Association of Anaesthetists published guidelines aimed specifically at preventing such events. Structured processes to prevent inadvertent use of a glucose-containing fluid to flush an arterial line and regular blood glucose sampling from a location other than the arterial line are only partial solutions. However, a survey of management of arterial lines undertaken in 2013 indicated that this was a common problem, that many of the NPSA recommendations were not widely implemented and that almost one third of respondents were aware of ‘wrong flush’ errors on their unit and a further third in other locations within their hospital. In this Rapid Response in the BMJ, Tim Cook says now is the time for patient representatives, clinicians, regulators and industry to work together to achieve widespread implementation of an engineered solution to prevent arterial line errors.
-
Content ArticleThe objective of this review from Alani et al. is to draw attention to the risk factors, causes and prevention of surgical fires in facial plastic and reconstructive surgery performed under local anaesthesia and sedation using a review of the literature.
-
News ArticleThe surgeon at the centre of a body parts scandal operated on patients who were dangerously sedated so that their procedures could be carried out simultaneously, according to a leaked investigation seen by The Independent. Renowned hip surgeon Derek McMinn and two anaesthetists at Edgbaston Hospital, Birmingham, were accused of putting “income before patient safety” in the internal investigation for BMI Healthcare, which runs the hospital. It comes after a separate review found that McMinn had hoarded more than 5,000 bone samples from his patients without a licence or proper permission to do so over a period of 25 years, breaching legal and ethical guidelines. Police are investigating a possible breach of the Human Tissue Act. According to the report on sedation by an expert from another hospital, the two anaesthetists, Imran Ahmed and Gauhar Sharih, sedated patients for so long that their blood pressure fell to dangerous levels in order to allow McMinn to carry out near-simultaneous surgery. It found this meant long delays in the operations starting, with one sedated patient being subjected to prolonged anaesthesia for longer than one hour and 40 minutes – recommended best practice is 30 minutes. Another patient was apparently "abandoned" for an hour and 26 minutes after their surgery was only partially completed while McMinn began operating on another patient. The report’s author, expert anaesthetist Dr Dhushyanthan Kumar of Coventry’s University Hospital, said this was unsafe practice by all three doctors and urged BMI Healthcare to carry out a review of patients to see if any had suffered lasting brain damage. Both anaesthetists work for the NHS – Ahmed at Dudley Group of Hospitals, Sharih at University Hospitals Birmingham – without restrictions on their ability to practise. Read full story Source: The Independent, 30 September 2020
-
Content Article
'Stop before you block' poster (Safe Anaesthesia Liaison Group)
Claire Cox posted an article in Resources for staff
This poster produced by the Safe Anaesthesia Liaison Group, is aimed at theatre staff - especially anaesthetists. it is to ensure they have a second checker when it comes to administering an anaesthetic block. -
Content ArticleThe Safe Anaesthesia Liaison Group (SALG)'s quarterly patient safety updates contain important learning from incidents reported to the National Reporting and Learning System (NRLS). The Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists would like to bring these safety updates to the attention of as many anaesthetists and their teams as possible.
