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Content ArticleSuccessful day surgery requires a day surgery team with the correct knowledge and skills to enable safe, early recovery and discharge but there is an absence of national guidance on supporting competencies. Applying in-patient competency criteria is inappropriate as this pathway is not aimed at promoting early discharge. This joint publication between AfPP and BADS (the British Association Of Day Surgery) provides recommendations for core competencies for adult day surgery through (1) admission, (2) anaesthetic room, (3) theatres, (4) first-stage recovery and (5) second-stage recovery and discharge. They are relevant for staff new to or after a long absence from day surgery and acknowledge some members of the day surgery team may include non-registered practitioners. All can be used as a reference for workbook competency documents in place or in development.
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Content ArticleDoctors are taught from medical school about the benefits of IUDs, and often encourage patients that they are a good contraceptive option. However, recent media attention on the pain that some women suffer when having their IUDs fitted has started conversations about the need for cervical blocks and more honest counselling of women about the procedure. Rebekah Fenton, adolescent medicine fellow at Lurie Children's Hospital of Chicago, joins us to talk about how she counsels her patients, and why the most important thing is to make sure women are in charge of their reproductive healthcare decisions.
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Content ArticleIntrahospital transport is a common occurrence for many hospitalised patients. Critically ill children are an especially vulnerable population who experience preventable adverse events at least once a week, on average. Transporting these patients throughout the hospital introduces additional hazards and increases the risk of adverse events. The transport process can be decomposed into a series of steps, each incurring specific risk. These risks are numerous and few of these risks are specific to the transport process. There is a paucity of literature available on paediatric intrahospital transport and related adverse events. Elliot et al. recently reviewed the Wake Up Safe database, a paediatric anesthesia quality improvement initiative across member institutions to disseminate information on best practices, for paediatric perioperative adverse events associated with anaesthesia-directed transport. The authors present several examples of airway and respiratory events taken from the database and discuss the complexity of the transport process.
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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 -
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
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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
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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
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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
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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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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
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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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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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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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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 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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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.
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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.
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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.
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Content ArticleThe Association for Perioperative Practice (AfPP) is calling for action to be taken after a recent never events report suggests little progress has been made to prevent errors within the perioperative environment.
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Content ArticleRob Hackett, Patient Safe Network, in the video below discusses the danger of Indistinct chlorhexidine which can easily be mistaken for other colourless solutions. He highlights the story of Grace Wang, who in 2010 had antiseptic solution injected into her epidural. She nearly died and was left paralysed. Indistinct chlorhexidine was mistaken for saline. The investigation recommended all skin antiseptic solutions to be coloured in a way that distinguished them. Sadly this recommendation isn't followed. Accidental chlorhexidine injections continue to occur and there are many more examples. This same error continues to play out again and again throughout the world. There’s no need for these indistinct solutions and safer distinct versions and those enclosed in swab sticks are already in use in many hospitals without problem and at no extra cost.
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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 ArticleIt has been estimated that, on average, a serious mistake in medication administration occurs once in every 133 anaesthetic medications. Anaesthetic medications often have a narrow therapeutic window, raising the potential for adverse outcomes including harmful physiological disturbances, awareness, anaphylaxis and even death. Marshall and Chrimes in this editorial examine the causes of the medication‐handling problem and discuss solutions that address the human factors considerations.
