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Found 116 results
  1. Content Article
    This 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.
  2. Content Article
    This tool was developed collaboratively between the Association for Perioperative Practice (AfPP), NHS England (NHSE) and BD to guide perioperative staff in selecting the most appropriate skin preparation solution for respective surgical procedures. By providing a combination of cues pre-defined and selected by the user, this tool recommends the most appropriate surgical skin antiseptic solution, method of use, technique, and precautions. The development of this clinical interactive decision-making tool provides healthcare professionals with evidence-based information at their fingertips to manage surgical site skin preparation effectively. This facilitates clinical decisions in practice, saving time and reducing harm.
  3. Content Article
    This 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.
  4. Event
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    This 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
  5. Event
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    The 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
  6. Content Article
    This 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.
  7. News Article
    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
  8. Content Article
    Across 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.
  9. News Article
    The GMC has responded to senior medical leaders’ frustration at news that the Government is again delaying long-promised plans for its reform which would ease the strain felt by doctors. Its chief executive said its Council shared widespread disappointment at the hold-up in changing the legislation – which was expected this year, but will not now happen until 2024-25. Charlie Massey told Independent Practitioner Today: "Physician associates and anaesthesia associates are an important part of the health workforce and we welcome progress to bring them into regulation, which we will do within 12 months of legislation being laid by Government. "But we are disappointed that the outdated legislation for doctors will not be replaced at the same time. "The current framework stops us from being responsive and flexible in how we address patient safety concerns and register doctors to join the UK workforce. That isn’t good for patients and puts unnecessary strain on doctors. "The Government has said that it expects to deliver reforms for doctors as a priority following its work on physician associates and anaesthesia associates." Mr Massey called for a clearer commitment on the specific timing of that work, adding that the GMC wanted to progress better regulation for both doctors and medical associate professionals (MAPs) as soon as the Department of Health and Social Care laid the necessary legislation. "It is now the department’s decision when and how to implement these changes. When the department does implement these changes, we will be ready to start the process to put the reform changes into practice," he said. Read full story Source: Independent Practitioner Today, 9 August 2022
  10. Content Article
    This is part of our series of Patient Safety Spotlight interviews, where we talk to people working for patient safety about their role and what motivates them. 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.
  11. Event
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    The 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
  12. Content Article
    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.
  13. Content Article
    This 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.
  14. News Article
    The NHS is facing a “time bomb” and will be forced to cancel or delay around 8 million operations each year by 2040, due to a lack of consultant anaesthetists across the services. The Royal College of Anaesthetists (RCOA) said the current shortage of at least 1,400 staff across the UK means millions operations will not be able to take place. The college has warned its speciality is facing a “perfect storm” of limited training places, poor retention and an ageing workforce with 39 per cent nearing retirement age. The analysis found as demand for surgeries continue the need for anaesthetists is due to increase by 3.85 per year, meaning the NHS will need around 25,000 doctors in these posts by 2040. Dr Fiona Donald, president of the RCOA said: “The NHS is facing an anaesthetic workforce time bomb. We already have profound workforce shortages that are preventing huge numbers of operations from taking place – and unless urgent action is taken, the problem is going to worsen. “We would welcome government funding for additional anaesthetic training posts. One hundred additional posts per year would start to plug the gap and help get the UK back on a sound footing to be able to address the waiting list backlog. Without this investment, we foresee impacts to patient care and a further impact on the mental health of our current workforce – they need to be able to prioritise their own health and that of their families alongside the focus they already place on the health of patients and the public.” Read full story Source: The Independent, 22 February 2022
  15. Content Article
    Surgery is lifesaving or life-enhancing for millions of patients every year. However, the operation is not in itself an isolated ‘event’: it is part of a process which includes preparation and recovery. Ensuring the quality of the entire perioperative pathway is important to achieving the best possible outcome for every patient.  This guidance is intended to be used by primary care, surgeons, anaesthetists, perioperative teams and preoperative assessment (POA) services. It applies to all patients who are being considered for surgery, or are on a waiting list for surgery in the non-emergency setting, irrespective of the magnitude of procedure or the type of anaesthesia contemplated. Its recommendations will support the care of individual patients, the recovery of elective services, and achieving key goals of the NHS Long Term Plan including reducing health inequalities and preventing serious health deterioration.
  16. News Article
    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
  17. Content Article
    Surekha 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. 
  18. News Article
    A perfect storm of pandemic pressures, changes to the medical curriculum and inadequate Health Education England funding threatens to leave 700 anaesthetists without a job this summer, HSJ has learned. The news comes as the NHS prepares to tackle the huge backlog of elective care work that has built up during the pandemic. Anaesthetists will play a critical role in the recovery effort. Each year around 300 higher training, or ST3, places for anaesthetists are offered by the NHS. However, this year there are over 1,000 applicants for these posts. The oversupply has been created by the inability of trainees to seek work overseas because of the pandemic and a change in the curriculum overseen by the Royal College of Anaesthetists. Royal College of Anaesthetists’ council member Helgi Johannsson told HSJ he was concerned trainees could become “so demoralised” after failing to secure a a job that they might switch to another specialty. “We need those trainees to come through,” he said. “There is a shortage of anaesthetists with around 10 per cent of consultant jobs unfilled and we need to protect our supply line and get on top of our elective backlog.” Read full story (paywalled) Source: HSJ, 7 May 2021
  19. Content Article
    Effective communication is critical for patient safety. One potential threat to communication in the operating room is incivility. Although examined in other industries, little has been done to examine how incivility impacts the ability to deliver safe care in a crisis. Katz et al. sought to determine how incivility influenced anaesthesiology resident performance during a standardised simulation scenario of occult haemorrhage.
  20. Content Article
    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.
  21. Content Article
    Anaesthesia safety checklist from the World Health Organization (WHO) covering: before induction of anaesthesia operating room operative procedure list postoperative care.
  22. News Article
    More than a million patient operations could be delayed because of widespread shortages of anaesthetists in the NHS – with 9 out of every 10 hospitals reporting at least one vacancy. As coronavirus paralysed the NHS earlier this year, more than 140,000 NHS patients have already waited over a year for treatment. The Health Foundation has warned that 4.7 million fewer patients have been referred for treatment because of the impact of coronavirus on NHS services. The Royal College of Anaesthetists (RCOA) told The Independent the scale of the vacancies was getting worse and labelled it a “workforce disaster” that could cost patients’ lives and have a widespread impact on hospital services. Read full story Source: The Independent, 22 November 2020
  23. Content Article
    In her latest blog, Sally Howard talks about the importance now more than ever of listening to and looking after each other. Making your voice heard. Listening to and appreciating those around you. Looking after yourself.
  24. News Article
    An anaesthetist who had been drinking before an emergency caesarean that led to the death of a British woman should serve the maximum three years in jail if convicted and should be banned from working as a doctor, a French prosecutor has demanded. Helga Wauters is on trial in Pau, south-west France, for the manslaughter of Xynthia Hawke in 2014. She is accused of starving Hawke of oxygen for up to an hour after pushing a ventilation tube into the wrong passageway. Orlane Yaouang, prosecuting, described the scene in the operating theatre when Hawke turned blue as “carnage” and spoke of the “surreal situation” in which the panicked hospital staff called the emergency services. Read full story Source: The Guardian, 9 October 2020
  25. Event
    Two patient safety lectures at this year's Annual Meeting of the American Society of Anesthesiologists: 10:00-11:00 - Is safety becoming the poor stepchild of quality? Presented by: Matthew B. Weinger, MD, MS 13:00-14:00 - The APSF: Ten patient safety issues we’ve learned from the COVID pandemic. Moderator: Mark A. Warner. Further information
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