The SALG Patient Safety Updates contain important learning from incidents reported to the National Reporting and Learning System (NRLS). The RCoA and the Association aim 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 time period.
Spotlight on medication safety errors
Last year, SALG set up a short life working party to consider medication errors in anaesthesia and actions that could be taken to reduce the frequency of these types of errors. The working party included representatives from a variety of stakeholder groups.
The findings of this working party were presented to the SALG Patient Safety Conference on the 31st October. A detailed report to be submitted to SALG in the New Year will recommend that SALG undertake a number of actions to support implementation of pre-filled syringes in NHS Trusts/Boards. These recommendations are supported by NHS England, the Faculty of Intensive Care Medicine (FICM) and clinical pharmacy colleagues. Information about the potential benefits of pre-filled syringes is available on the SALG website. If you have an interest in this area and would like further information, please contact [email protected].
Safe Anaesthesia Liaison Group: Use of prefilled syringes in anaesthesia
Airway hazards
SALG is aware of a continued risk of aspiration of the plastic backing supplied with items commonly found in theatre areas such as ECG electrodes and silicone tape products. In 2020, a National Patient Safety Alert was issued that required NHS hospitals to introduce controls on purchasing to ensure that ECG/ECT electrodes for use in theatres, ECT suites and emergency areas have either large sheet backing for multiple electrodes or fully coloured or patterned individual backing.
HSSIB report: Positive Patient Identification
SALG would like to highlight an HSSIB investigation of cases of mistaken patient identification, that contains recommendations relevant to anaesthetists and departments of anaesthesia.
Prevention of Future Deaths reports
All Prevention of Future Deaths reports received by the RCoA/Association of Anaesthetists are reviewed by SALG and a joint response produced. Below is a sample of those with national level learning for anaesthetists.
Reports received since the previous PSU are listed below, please click to view learning points:
Misdiagnosis of malignant pyrexia
Field Safety Notice - Drager Atlan Anaesthetic Machines/Ventilators
Drager have issued a ‘Field Safety Notice (FSN)’ about some of their Atlan machines in October this year, which is available on the MHRA website.
The position of SALG is that it is not acceptable that anaesthetic machines with faulty ventilator motors are
used for patient care, particularly for general anaesthesia where patients are dependent on mechanical ventilation to keep them alive.
If your hospital has this model of machine in theatres, we would strongly advise that you check the serial number against those included in the alert and take action accordingly.
Review of clinical incidents
Following is a review of incidents reported to the NHS in England and Wales in the period from 1 October 2023 – 31 March 2024.
Stroke following anaesthesia – possible air entrainment by faulty fluid warmer
[Patient in their 30s] had a hernia repaired under combined GA and spinal anaesthesia. Once the procedure had finished and the patient woken up, they complained of being unable to move their legs. This was initially...
Pre-operative assessment
During the pre-operative assessment before elective surgery of a patient with multiple medical comorbidities, no physical examination was undertaken. Despite an ejection systolic murmur being documented several times in the notes, an ECHO had never been requested.
Perioperative care of patients with dementia
An elderly patient with complex co-morbidities was admitted from a care home with probable large bowel obstruction. The patient appeared delirious on the ward and could not tolerate NG tube insertion.
Deterioration whilst awaiting theatre
Three days after an oesophagectomy, a patient in their 70s started complaining of abdominal pain. After 5 days of conservative treatment a CT revealed extra luminal contrast leak at the pyloroplasty site, free fluid in the abdomen, pleural effusion, atelectasis, small pneumothorax and a splenic infact.
Transfer
CASE 1
A patient who had recently undergone a laparoscopic procedure to the oesophagus at a tertiary centre was transferred back to their local hospital for post-operative care.
Familiarity with equipment (out of hours)
A Patient was admitted for emergency cardiac catheterisation in a state of cardiogenic shock with ongoing chest pain and pulmonary oedema . The anaesthetic team were called urgently. An anaesthetist, who was unfamiliar with the equipment, arrived without an ODP, but could not activate capnography.
Tracheal injury
This content has been developed for SALG by the Association for Cardiothoracic Anaesthesia and Critical Care
A patient suffered tracheal injury secondary to difficult placement of a double lumen tube. Bronchoscopy revealed defectin the left bronchus + injury to the distal trachea.
Following MDT - patient put on VV ECMO, and the injury repaired. The patient is recovering on intensive care unit, still awaiting surgery for lung cancer.
Perioperative anaphylaxis
This content has been developed for SALG by the Perioperative Allergy Network
A multi-co-morbid patient underwent general anaesthesia and regional nerve blocks for reverse shoulder replacement. Induction of anaesthesia was uneventful and the patient was placed into beach chair position in the anaesthetic room.