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Anaesthetic techniques and equipment have greatly improved over the last 60 years, as has the training and safety equipment to protect patients. If you are in good health modern anaesthetics are really very safe. However, all procedures have some risks and it is important that patients are fully informed and that the anaesthetist discusses the procedure and the risks with the patient, taking into account the patient's medical history. At Patient Safety Learning we believe that sharing insights and learning is vital to improving outcomes and reducing harm. That's why we created the hub; to provide a space for people to come together and share their experiences, resources and good practice examples. We have pulled together 9 useful resources about anaesthesia that have been shared on the hub. They include insights from anaesthetists and examples of good practice. 1 Patient Safety Spotlight interview with Annie Hunningher, Consultant Anaesthetist at the Royal London Hospital, Barts Health In this interview, 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. 2 Implementing human factors in anaesthesia: guidance for clinicians, departments and hospitals Human factors is an evidence-based scientific discipline used in safety critical industries to improve safety and worker wellbeing; implementing human factors strategies in anaesthesia has the potential to reduce the reliance on exceptional personal and team performance to provide safe and high-quality patient care. A three-stage Delphi process was used to formulate a set of 12 recommendations: these are described using a ‘hierarchy of controls’ model and classified into design, barriers, mitigations and education and training strategies. 3 Reviewing ‘work as done’ to prevent wrong site anaesthetic blocks: An interview with Marsha Jadoonanan, HCA Healthcare UK Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), shares a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’. 4 Hysteroscopy pain: A discussion with anaesthetists. A blog by Helen Hughes In this blog, Patient Safety Learning’s Chief Executive, Helen Hughes, reflects on a recent discussion about hysteroscopy and patient safety at a conference in January 2023, hosted by the Association of Anaesthetists. 5 Reducing intubation errors: A simple, accessible checklist to improve safety and support staff 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. 6 Handling injectable medications in anaesthesia: Guidelines from the Association of Anaesthetists These guidelines from the Association of Anaesthetists aim to provide pragmatic safety steps for the practitioner and other individuals within the operative environment, as well as short- to long-term goals for development of a collaborative approach to reducing errors. 7 RCOA infographic - Common events and risks for children and young people having a general anaesthetic This 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. 8 Association of Anaesthetists case reports: Invaluable learning from mistakes In this clinical case report for the Association of Anaesthetists, the authors reflect on the importance of error reporting and implementing learning from clinical mistakes. They look at several error-related incidents and examine key learning points. They highlight that cases that do not result in serious harm to the patient are not prioritised for entry into databases or national audits, meaning they are less likely to be the subject of system-based improvement projects when compared with more ‘serious’ events. They identify that this may cause gaps in clinicians' awareness of potential risks and error traps. 9 The normalisation of patient care: Developing global guidance on securing an airway In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia. Do you have a resource or story about anaesthesia to share? We’d love to hear about it - leave a comment below or join the hub to share your own post.

Normalisation of patient care refers to the process of standardising healthcare practices to ensure consistent, high-quality care for all patients, regardless of their background or condition. This concept is vital in today’s healthcare systems, where variability in care can lead to disparities in outcomes. By normalising care, healthcare providers aim to reduce these disparities, improve patient outcomes and enhance the overall efficiency of healthcare delivery. However, if poor care becomes normalised; i.e., treated as routine, it can have detrimental effects on patients and their outcomes. In this blog, Dawn Stott discusses the importance of consistency in care delivery, why healthcare systems must continue to develop and refine strategies for normalising care, and how she and her colleagues are developing global guidance on securing an airway when delivering anaesthesia.  Consistency in care delivery One of the primary goals of normalisation is to ensure that every patient receives the same standard of care. This means that the treatment a patient receives should not depend on the time of day, the healthcare provider’s experience or the facility where they are treated. Standard protocols and guidelines help to minimise variations and ensure that all patients receive evidence-based care. When care is standardised, it often leads to better health outcomes. For instance, standard protocols for managing chronic diseases like diabetes or hypertension ensure that all patients receive the most effective treatments, reducing the risk of complications and improving long-term health. Normalisation also enhances the efficiency of healthcare delivery. Standardised protocols streamline processes, reduce the need for unnecessary tests or treatments, and make it easier for healthcare providers to coordinate care. This, in turn, can reduce costs and improve the overall functioning of healthcare provision. An example of a change to a standardised way of working is the securement of an intravenous (IV) cannula. Many articles have been written on the subject of IV securement, which essentially broke down the silos and made it clear, based on evidence, that after insertion of the cannula, the next most significant consideration was the securement of the device.[1][2] Historically securement was achieved with tapes, ties or sutures. Adhesive securement devices became the preferred method over sutures because they offered securement without additional skin punctures. The introduction of the IV dressing for cannula securement was revolutionary and is now a custom practice internationally. Developing global guidance on securing an airway In a recent survey, and following several professional focus groups, our project team have found that inflammatory damage to a patient’s skin following anaesthesia was a ‘real’ problem because of the way the airway was secured. There is a risk of these practices becoming normalised and therefore not being reported as a patient incident. As a result of a freedom of information study undertaken by the project team, the information gained suggests that many hospitals do not measure poor airway management outcomes and there does not appear to be any central database to support this either. There is a risk of damage to a patient’s skin when tapes are used to secure the airway. However, this is often not reported because it is ‘just the tape’ causing the harm. As a result of this type of practice happening quite often, it has become accepted and engrained into healthcare practice, similar to how it used to be with an IV cannula, and is another example of where normalisation of a practice is detrimental to a patient’s care. To improve this, a group of individuals have come together to work on developing global guidance on securing an airway and delivering anaesthesia safely in the pursuit of precision and vigilance. The idea was that as a project team we could, together, envision a future where anaesthesia safety is not just an aspiration but a standard of care that we exceed every single time.[2] Our goal is to standardise securing an airway to eliminate harm to a patient’s skin, airway displacement and infection risks. Although the project team appreciate that anaesthetics is deemed to be one of the safest areas of healthcare practice, our project’s aim is to provide evidence that current practices in airway securement are unsafe and are leading to patient harm, and that a better, licenced and regulated, solution is needed. Tapes and ties are still the mainstay for securing an airway in operating theatres and these methods are unlicensed with varying adhesive capabilities, which could cause inadequate safety to the patients. With this evidence we hope to influence nationally recognised bodies to establish clear guidelines and recommendations to support safer patient outcomes through education and learning. Strategies for effective normalisation of care Healthcare providers may resist the implementation of standardised protocols, particularly if they feel that these protocols limit their clinical judgment. Overcoming this resistance requires effective communication and education about the benefits of normalisation, including: Developing and implementing clinical guidelines, which should be evidence-based with regular updates. These guidelines will serve as the foundation for standardisation of procedures across different settings and providers. Ongoing training and education, which are crucial to ensuring that providers understand and can effectively implement standardised protocols. The education should form the basis for induction as well as continuous professional development. Continuous monitoring and evaluation, which are essential to ensure that normalised efforts are effective. This will involve tracking outcomes, gathering feedback from both patients and providers, and adjusting care protocols as required. Moving forward, healthcare systems must continue to develop and refine strategies for normalising care, balancing the need for standardisation with the importance of individualised, patient-centred treatment. By doing so, a more equitable and effective healthcare system can be provided for all. Conclusion This year’s World Patient Safety Day slogan is ‘Get it right, make it safe’. Our project is all about getting it right and making the securing of an airway safe for the patient. The team are aiming to highlight the importance of prioritising patient safety over financial constraints. As healthcare professionals it is important to raise awareness of the value it will have to the patient; i.e., the quantity of harm to the patient to promote the value of the quality outcomes for the patient versus the cost of the product. Healthcare is a high-risk industry and professionals should follow guidance developed from the best available evidence (NICE guidance) rather than any traditional or ritualistic practice. As practitioners we are accountable for our actions and safety is everyone’s responsibility. References Barton A. Universal Adhesive Vascular Access Securement with GripLok Devices. BJN, 2020. https://doi.org/10.12968/bjon.2020.29.8.S28 Docherty V. The Importance of Airway Training. CSJ, 2024.

Mandy Anderton is a Clinical Nurse specialising in learning disability and a hub Topic Leader. In this new blog, Mandy explains how they are using shared decision making and reasonable adjustments to implement a new care pathway, where patients with a learning disability needing to undergo a medical investigation can receive deep sedation within their own home.  Working with patients, carers, relatives, anaesthetists and others, the aim is to improve access to important medical investigations with minimal distress, where other avenues have been exhausted.  Health inequalities and barriers to care People with learning disabilities experience higher levels of physical ill health, yet they face serious health inequalities and have lower life expectancy, dying on average 25 years sooner and frequently from avoidable and preventable conditions [1]. An inability to express pain or general feelings of being unwell (or this resulting in behaviour described as challenging) can lead to delays or problems with diagnosis or treatment, identifying needs and providing appropriate care. People with a learning disability might struggle to engage with medical interventions due to lack of understanding or fear, whilst uncertainty amongst medical professionals about capacity and consent can all lead to further delays. People with learning disabilities often struggle to engage with diagnostic tests like having blood taken or having a scan. This can lead to delays in care and treatment and have an impact on health outcomes. Reasonable adjustments Under the Equality Act 2010, there is a legal duty for public bodies to make reasonable adjustments for people with a learning disability. Equality is not necessarily about treating everybody the same. Rather, it is treating a person with a learning disability in such a way that the outcome for that person can be the same. Reasonable adjustments can be put in place, for example prescribing small doses of oral sedation to reduce anxiety or undertaking desensitization and preparation work on an individual basis. But these things do not work for everyone and can take time (which is no use in urgent situations). Clinical holding is also not always appropriate to every situation or individual. Bringing diagnostic tests to the home Salford Care Organisation (part of the Northern Care Alliance) has started to explore the use of deep sedation in the home to support people to have essential investigations, with the additional option of an anaesthetic if needed. Perceived benefits of these changes to practice are earlier diagnoses and treatment of medical conditions. Both of which promote equality and reduce mortality and premature death for people with a learning disability. The general idea is that when blood tests or other diagnostic tests or procedures are required (scans can be tricky for people to engage with also), GPs would be able to refer direct to a dedicated anaesthetic clinic for this support. Mental capacity Healthcare professionals need to work within the Mental Capacity Act (2005) and if the patient’s capacity is in question, a Mental Capacity Assessment is undertaken. If the person is considered to lack capacity, then decisions will be taken in their best interest. This process will include relevant medical professionals, family, and carers. If the person does not have a family member or friend to advocate on their behalf, then an Independent Mental Capacity Act Advocate will be asked to join these discussions. Best interest decision-making Least restrictive options are always considered and often tried first– this might be desensitization work, longer appointment times, giving oral sedation, working up to possible clinical holding or deep sedation or anaesthesia if needed. Legally the person proposing the procedure is always the lead for best interest and capacity but others will provide significant input. It is likely there will be on-going meetings and different best interest decisions are made as different interventions are tried and considered. The best interest decision process will consider the pros, cons of each intervention, always starting with least restrictive option and working upwards if needed. The likely consequence of doing nothing will also be considered against risk of anaesthetic and distress to the person and weighed up against the risk of not treating a possible underlying health issue. Safety considerations and risk assessment Safety is our priority. Fiona Armstrong, Consultant Anaesthetist, developed a policy around the new approach and this contains a lot of the detail around how we manage risk. The policy was approved last year, and we have attached the document at the bottom of this page for anyone interested. Fiona has also shared some of the key safety features below: The patient has to be suitable. They cannot be a predicted high anaesthetic risk. This would include certain medical problems, anticipated difficult to manage airways, high BMI or previous problems with anaesthesia. The home has to be suitable – within 30mins blue light transfer of the hospital. The ambulance team also needs to be able to safety extract the patient from the location that sedation is administered. Anaesthetist and anaesthetic assistance, trained in transfer, attend with all kit to be able to safely administer oxygen, secure IV access, give supportive medications or provide a full anaesthetic should an adverse event occur. The patient’s vital signs are monitored as soon as sedation takes effect and for the journey. Full area for immediate administration of anaesthetic is set up at the hospital. Home visit occurs prior by the ambulance team to ensure suitability and plan number of staff/extraction kit. Patient’s support team are involved in the planning process of how, when and where sedation is administered to minimise distress and improve safety whilst medication takes effect. We are at the very early stages of exploring this as a care pathway and only two people have been through the process so far, both cases have gone smoothly. Many others have managed with oral sedation to make it to the carpark and have the deep sedation administered there and others are currently undergoing planning and the best interest process. Case study - John A gentleman with severe learning disabilities and autism, John has a longstanding fear of needles, medical professionals and environments. Blood tests, an echocardiogram and ultrasound scan were needed to help identify any underlying, and potentially serious, medical cause for his swollen ankles. Opportunities for desensitization had been exhausted and attempts to take blood with the support of regular oral sedation had proved unsuccessful. Working together and within the legislation of the Mental Capacity Act (2005), John’s family, support team and health care professionals from both general health services and the Adult Learning Disability Team came together to form an individualised plan, which would enable John to have deep sedation (with the option of a general anaesthetic if needed) in his own home before being safely transported to hospital for further care and treatment. Feedback I’ve spoken to both of John’s carers (he lives in 24-hour support) and his mother. His mother couldn’t praise the support enough, saying how much re-assurance it had given her knowing that his health concerns had been taken seriously and investigated. She is more reassured for the future and thinks the pathway should be available everywhere. John’s carers also felt it suited his needs well: “Fiona, the anaesthetist, went to his home and basically just worked within John’s usual routine, which was so important as John is also autistic and has very rigid routines that he needs to adhere to. John was totally calm and does not appear to have been adversely affected in any way at all. He went straight back to his usual self, following return from hospital, as if nothing had happened”. Chris Connell, Head of service (supported living), Aspire for Health and Intelligent Care and Support Reflections so far Resources are needed to make this into a recognised referral pathway with dedicated theatre time. At the moment, it happens a little ‘ad-hoc’ and people are fitted in when our anaesthetist can find gaps on theatre lists. Funding is currently being considered. Working collaboratively has been key, with clear coordination and on-going meetings to revisit decision-making where needed and agree fresh plans. The visit to give John deep sedation in his home was very carefully planned beforehand to help ensure it ran in line with his routines and had the very best chance of success. Listening to John’s carers and family were key in gathering information about how best to support him. The service is completely personalised, which works best for people with a learning disability. Sedation can be given in the home, where a person is most comfortable and relaxed and can fit around their usual routines. So far, we have seen people get the medical investigations they needed in a timely manner with little, if any, stress to themselves. I’m not sure how we would have moved forward for John without this process as we had exhausted all other avenues. We need to continue to connect with key stakeholders such as community teams and hospital specialists. To make sure they know the service exists and to consider it for patients who need investigations, where other reasonable adjustments have failed. [1] (Learning Disability Mortality Review Programme, 2020) Share your thoughts Do you or someone you care for have a learning disability? Perhaps you work in healthcare and would like to help reduce the inequalities experiences by people with a learning disability. What do you think about the approach described in the blog? Please share your thoughts by commenting below (register for free first) or contact us at [email protected]. You can also get in touch with Mandy directly at [email protected] to find out more about this work. Related content Nobody left behind: Improving the health of people with learning disabilities and reducing inequalities across primary care How can GP practices help improve health outcomes for people with learning disabilities? Interview with a Community Learning Disability Nurse CS008 V1 Home Sedation and Transfer Service for Patients with Complex Needs requiring Hospital investigations and treatment (002) (1).pdf

Marsha Jadoonanan, nurse and Head of Patient Safety and Learning at HCA Healthcare UK (HCA UK), spoke to us about a recent opportunity to learn from patient safety incidents involving wrong site anaesthetic blocks. She describes the new learning approach she and her colleagues used, which focused on engaging staff working in a variety of roles to create a safe space to focus on identifying ‘work as done’.