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Found 116 results
  1. Content Article
    These 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.
  2. Content Article
    The 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.
  3. 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.
  4. News Article
    An NHS hospital has admitted it failed to properly anaesthetise a patient who was operated on while conscious – leaving her with post-traumatic stress disorder (PTSD) and recurring nightmares. The woman, who has chosen to remain anonymous, said she screamed out as the gynaecological surgery at Yeovil District Hospital began to operate, but could not be heard through her oxygen mask as the surgeon cut into her belly button. Medical negligence lawyers said she was given a spinal rather than general anaesthetic during the procedure at the hospital in Somerset last year. She remained conscious while a laparoscope – a long camera tube – was placed inside her, and her abdomen was filled with gas. Her law firm Irwin Mitchell said that an increase in blood pressure had alerted staff to her discomfort, but that the procedure was continued. The woman, who is in her 30s, said: “While nothing will change what has happened to me, I just hope that lessons can be learned so no one else faces similar problems in the future." A spokeswoman for Yeovil Hospital said the incident was the result of “a breakdown of communication” which “led to the use of a different anaesthetic to that normally required for such an operation”. Read full story Source: The Independent, 10 December 2019
  5. 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.
  6. 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.
  7. 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. 
  8. 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
  9. 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
  10. Content Article
    A recent paper (from clinicians and Human Factors specialists at the Royal Surrey NHS Foundation Trust) jointly supported by Elsevier and BJA Education clarifies what Human Factors (HF) is by highlighting and redressing key myths.  The learning objectives from the paper are as follows: Identify common myths around HF Describe what HF is Discuss the importance of HF specialists in healthcare Distinguish the importance of a systems-based approach and user-centred design for HF practice.  It explains that HF is a scientific discipline in its own right, a complex adaptive system very much like healthcare. Its principle have been used within healthcare for decades but often in an informal way.  A link to the summary of the article on Science Direct and further links to purchase the paper can be found here: https://www.sciencedirect.com/science/article/abs/pii/S2058534923000963?dgcid=author 
  11. 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
  12. 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
  13. 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
  14. 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
  15. 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
  16. 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.
  17. 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.
  18. 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.
  19. 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.
  20. 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
  21. 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.
  22. Content Article
    The 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.
  23. Content Article
    There are three main aspects of the Operating Department Practitioner (ODP) role; namely, anaesthetics, surgery and post-anaesthetic care. There are some overarching qualities that are necessary for any ODP. These include excellent communication skills including verbal, non-verbal and written. Treating patients with dignity and respect, maintaining confidentiality throughout.
  24. Content Article
    The Safe Anaesthesia Liaison Group (SALG) Patient Safety Updates contain important learning from incidents reported to the National Reporting and Learning System (NRLS). The RCoA and the AAGBI would like to bring these Safety Updates to the attention of as many anaesthetists and their teams as possible.  The updates are published quarterly and contain data from an earlier three month period. To join the safety network, and receive patient safety updates direct to your inbox, please contact the SALG administrator at admin@salg.ac.uk .
  25. Content Article
    This article from Peden et al. reviews of some of the key topics and challenges in quality, safety, and the measurement and improvement of outcomes in anaesthesia. Topics covered include medication safety, changes in approaches to patient safety, payment reform, longer term measurement of outcomes, large-scale improvement programmes, the ageing population, and burnout. The article begins with a section on the success of the specialty of anaesthesia in improving the quality, safety, and outcomes for our patients, and ends with a look to future developments, including greater use of technology and patient engagement.
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