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 three month period.
Blue dye and anaphylaxis
In response to communication from a member of the public, we would like to remind readers of a previous NHS alert and direct communication to health professionals about the risk of anaphylaxis from blue dyes used in marking sentinel nodes in breast surgery and in particular, Patent Blue V
Bleeding in the airway
“The patient had a cardiac arrest due to airway obstruction because of airway bleeding the night before. After handover the thoracic surgeons were asked to assess patient and perform a bronchoscopy...
Complication of thyroid surgery
“… elective total thyroidectomy and left neck dissection. Post-op period complicated by stridor on extubation...
Problem after ITU step down
“Patient received from ITU, appeared very poorly on admission. It was mentioned that patient was scoring 2
on handover but when we checked obs was scoring 10, and neuro obs 6...
Issues with IV line
Case 1: "Cardiac arrest leading to ECPR...
Case 2: "Alerted by emergency buzzer to cubicle. On attendance patient undergoing CPR....
Case 3: "While procedure being carried out, vascular consultant noticed that patient's right arm was swollen...
Myelinolysis secondary to sodium correction
“[Infant] with background of gastroschisis and ileostomy in situ. Under follow-up with gastroenterology....
Central venous line
“Patent became unwell on mobilisation with cardiorespiratory compromise and reduced level of consciousness...
Tracheostomy
Case 1: “Patient was admitted to intensive care after laparotomy for small bowel obstruction and ischemia...
Case 2: “The patient had a surgical tracheostomy inserted... It leaked air past the cuff into the patient's mouth and required high cuff pressures...
Hip fracture surgery
Case 1: “During performance of spinal anaesthetic under sedation patient became bradycardic with no palpable pulse...
Case 2: “Patient undergoing (cemented) distal femoral replacement for periprosthetic distal femoral fracture...