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Key recommendations All patients should be informed of the risks of general anaesthesia, including the possibility of AAGA, before their surgery. When consenting patients, practitioners should use a form of words that proportionately conveys the risks of AAGA. Consent for sedation should emphasise that the patient will be awake and therefore may have recall for at least parts of the procedure. Practitioners should identify certain situations or certain patient factors as constituting a higher risk for AAGA (including organisational factors such as overbooked or reorganised surgical lists) and highlight these at the WHO premeet/team brief. During induction of anaesthesia, practitioners should adhere to suitable dosing of intravenous agent, check anaesthetic effect before paralysis or instrumentation of the airway and maintain anaesthetic administration, including during transfer of patients (which is facilitated by a simple ABCDE checklist). If AAGA is suspected during maintenance (e.g., by patient movement), prompt attention should be paid to giving verbal reassurance to the patient, increasing analgesia, and deepening the level of anaesthesia. For cases requiring paralysis, the minimum dose of neuromuscular blocking drugs (NMBDs) that achieves sufficient neuromuscular blockade for surgery should be used, and the nerve stimulator is an essential monitor to titrate the dosing of NMBDs to this minimum. Where total intravenous anaesthesia (TIVA) is used, practitioners should adhere to the relevant recently published guidelines. At emergence, practitioners should first confirm that surgery is complete, then ensure NMBDs are adequately reversed before allowing the patient to regain consciousness. Practitioners should then manage the patient experience, particularly during awake extubation, by speaking to the patient. Cases of AAGA should be managed using the NAP5 pathway as a guide.

Issuing of controlled drugs within the operating department and key holding Ordering and transferring of drugs Unused controlled drugs Security requirements Disposal of controlled drugs.

Key points Medication errors are the most common type of error affecting patient safety and the most common single, preventable cause of adverse events. Medicines calculations can assist in preventing an inaccurate medicines dose from being administered to the patient, which could result in suboptimal therapeutic benefit and/or possible harm to the patient. It is crucial for IV infusion calculations to be accurate, because these medicines directly enter the venous system and generally have a prompt action. Therefore, there is limited possibility of removing the medicine if an error is made. Individual nurses and healthcare organisations must ensure that medicines calculation skills are developed and maintained in practice.

Safety recommendations: It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System. It is recommended that NHSX supports the development of interoperability standards for medication messaging. It is recommended that NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety. It is recommended that the Department of Health and Social Care should consider how to prioritise the commissioning of research on human factors and clinical decision support systems; particularly in relation to the configuration of software system alerting and alert fatigue, to establish how best to maximise clinician response to high risk medication alerts. It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines use. It is recommended that NHSX produces guidance for configuring the electronic discharge process, and how electronic prescribing and medicines administration systems should be interfaced with such a process.