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In healthcare, we often talk about 'never events'—serious incidents that should not occur if appropriate systems are in place. But what happens when they do occur? I recently had the great pleasure of working with a group of anaesthetic resident doctor colleagues on a patient safety project that began with exactly that question. Within a short period in 2025, our large UK teaching hospital experienced two wrong-sided peripheral nerve blocks after six years without a single reported incident. We wanted to understand why. Looking beyond individual error Both incidents occurred during a major transition: we were moving anaesthetic records, consent forms and safety checklists from paper to digital. At first glance, the timing felt more than coincidental. After initial governance processes were completed, our team used the Patient Safety Incident Response Framework (PSIRF)[1] to explore what had happened. Introduced in the NHS in 2022, PSIRF promotes a systems-based approach rather than searching for a single 'root cause'. It examines how elements such as people, tasks, tools and technology, environment and organisational factors interact to increase risk. For us, this shift in perspective proved crucial. Instead of asking “who made this mistake?”, we were able to consider “what conditions made this error more likely?”. What we found: small gaps in a complex system We brought together a multidisciplinary 'learning MDT', combining insights from staff interviews and systems analysis. A clear pattern emerged: no single failure caused these incidents. Instead, multiple small vulnerabilities aligned. One issue stood out. In our previous paper-based system, clinicians used a 'Stop Before You Block' (SBYB) sticker—a simple but effective visual cue prompting a final safety pause before performing a nerve block. During the digital transition, this physical prompt disappeared. Other contributing factors reinforced the problem: Staff worked under cognitive overload, juggling interruptions, changing plans and high-acuity patients. Digital consent processes made SBYB checks feel more cumbersome, drawing attention away from the patient and towards the computer. Poor visibility of surgical site markings increased the barriers to performing SBYB. Ergonomic challenges in anaesthetic rooms made equipment setup frustrating. Time pressure on theatre lists encouraged task compression. In both cases, clinicians skipped the SBYB pause entirely—not out of negligence, but because the system no longer reliably supported it. These events didn’t reflect individual failure. They reflected a system under strain during organisational change. From insight to action: designing safer systems We knew we couldn’t eliminate complexity from clinical environments, but we could design systems that make the safe action the easy action. We developed a multi-faceted improvement plan. 1. Strengthening standards and education We updated our local guidance, aligning it with national recommendations from the Safe Anaesthesia Liaison Group and Regional Anaesthesia UK.[2] We rebranded it as the 'Prep Stop Block LocSSIP' (Local Safety Standard for Invasive Procedures). We promoted this through clinical governance meetings and delivered targeted teaching to consultants, trainees and anaesthetic practitioners. To support sustainability, we embedded a training video into the anaesthetic resident doctor induction programme and uploaded it to our intranet. 2. Fixing friction in the system We addressed practical barriers: Improved access to longer ultrasound cables. Standardised surgical site markings to improve visibility. Explored integrating anaesthetic complexity into theatre scheduling. Trialled LED signs to indicate when the anaesthetic room is in use; thus creating a 'sterile cockpit' by discouraging interruptions during anaesthetic procedures. Introduced electronic tablets so consent forms could be viewed alongside the patient and checklist. Each of these changes aimed to reduce cognitive load and create space for safer practice. 3. Introducing a physical safety barrier Our most impactful intervention was the 'Prep Stop Block Lid'. We designed a lidded box displaying a safety infographic. Clinicians place prepared local anaesthetic inside and cannot access it until they complete the SBYB pause. This shifts safety from memory to physical design, creating a clear pause point in the workflow. We refined the intervention through Plan–Do–Study–Act (PDSA) cycles with frontline feedback before wider rollout. What we’ve learned so far Early data show improvements in process measures, including increased visibility of the SBYB step. Audits of Prep-Stop-Block compliance suggest an improvement from 34% during digital transition to 100% at most recent review. However, we remain cautious. We are still in a 'zone of vulnerability', where changes are ongoing and their full impact is unclear. Because never events are (fortunately) rare, it will take time to determine whether these interventions reduce harm. That said, several key lessons have already emerged: Never events are rarely about individuals. They arise from system conditions that make errors more likely. Digital transformation can unintentionally remove safety cues. We must actively design these back into new systems. Education and policy are necessary but insufficient. The most reliable safety interventions are embedded into workflow, especially physical or procedural 'forcing functions'. A call to action If your department is undergoing digital transformation, take a moment to ask: “What safety cues might we be losing—and how will we replace them?” We need to move beyond simply digitalising existing processes. Instead, we should use these transitions as opportunities to design safer, more resilient systems from the ground up. Because when it comes to patient safety, 'never' is not a guarantee, it’s a goal we must actively work towards. References https://www.england.nhs.uk/long-read/patient-safety-incident-response-framework/ https://www.salg.ac.uk/salg-publications/stop-before-you-block/

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’.

The Safe Anaesthesia Liaison Group (SALG) Patient Safety Conference will be held virtually this year on Thursday 23 November 2023. 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 a selected group or society (yet to be announced). 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 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

Energy-based devices, lasers and diathermy are some of the most commonly used pieces of equipment in operating theatres today. Dangerous emissions can be produced that affect the respiratory systems of everyone in the operating theatre. This study day will look at the occupational hazards of exposure to surgical plume in the operating theatre, as well as the associated risks to the surgical team, patients and visitors. It will also highlight how to assess risk and mitigate against the dangers of surgical plume and how to implement changes. Topics Include: Electrosurgery/diathermy/laser. Anaesthetic airway fires. Laparoscopic surgery aerosolisation. Health and Safety and risk assessment. Surgical plume. Register

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

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

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

Dr 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