Transcript Document

This presentation should be used in conjunction with the full publication:
Patient Safety Update including the summary of reported incidents relating to
anaesthesia 1 January to 31 March 2014.
PATIENT SAFETY UPDATE JUNE 2014
What is the Safe Anaesthesia Liaison
Group (SALG)?
• A joint committee of the RCoA, AAGBI, National safety organisations, NRLS
managers, patients and other organisations and individuals representing patient
safety issues across the UK
• SALG has a data sharing agreement under which critical incidents reported by
hospitals to the NRLS are provided for wider sharing
• The Patient Safety Update is a quarterly publication which is the mechanism for
sharing reported data
• This presentation provides a précis of the Patient Safety Update for June 2014
PATIENT SAFETY UPDATE JUNE 2014
Why discuss the Patient Safety Update
at M&M?
• Raise the profile of patient safety within departments.
• Learn from the experience of others.
• Use the slides that you find useful (there is no need to use them all).
• Slides should be used with the details in the full safety update.
• Add information from your own department.
• Feed back to [email protected].
PATIENT SAFETY UPDATE JUNE 2014
On the SALG Agenda
Patient Safety Conference 2014
•The date for the 2014 SALG Patient Safety Conference has been
confirmed as Wednesday 1st October 2014. This year the event will be held
in Belfast at the Belfast Waterfront Conference Centre. To book, or for
further information please visit the College website.
Residual anaesthetic drugs in cannulae and intravenous lines
•NHS England has issued a patient safety alert on the risk of residual
anaesthetic drugs in cannulae and intravenous lines, which can lead to
cardiac or respiratory arrest.
•The alert was issued in response to six incidents since 2011 of cardiac or
respiratory arrest due to residual anaesthetic drugs in cannulae reported
via the NRLS. The alert is available on the NHS England website. A previous
alert issued by the NPSA in 2009 applied only to children; the latest alert
highlights that adults also face this risk.
PATIENT SAFETY UPDATE JUNE 2014
Misconnections and an important
alert relating to G-size cylinders
Incident Report [1]
• Routine anaesthetic machine check identified a misconnection which could have
resulted in delivery of a hypoxic gas mixture. Site has no pipeline supply so machine
connected to large (G) oxygen and air cylinders via Schrader valves. Cylinders have a
bull nose connector to which a pressure reducing valve / Schrader valve is attached
prior to use. It is possible to interchange the air and oxygen valves so the incorrect
valve is attached to the cylinder. The pipeline will then connect with the Schrader
valve to the incorrect cylinder and air will be delivered through the oxygen
rotameter and oxygen via the air rotameter. This will result in the delivery of a
hypoxic gas mixture.
PATIENT SAFETY UPDATE JUNE 2014
Misconnections and an important
alert relating to G-size cylinders
Incident Report [2]
• Patient with asthma anaesthetised for knee surgery. Post induction patient was
difficult to ventilate with high airway pressures. Bronchospasm suspected and
treatment given… no improvement… consultant help summoned. Circle circuit
misconnection found. Expiratory limb was connected to Common Gas Outlet. It is
unclear how this occurred but the CGO is positioned close to the circle inlet / outlet
ports.
PATIENT SAFETY UPDATE JUNE 2014
Misconnections and an important
alert relating to G-size cylinders
Incident Report [3]
• A hospital clinical governance lead has reported to SALG that standard bull-nose
connectors (BS 341) on G size gas cylinders are of a universal size meaning that
valves/pipelines can be connected to the wrong type of gas.
© BOC (Image provided courtesy of BOC)
PATIENT SAFETY UPDATE JUNE 2014
Misconnections and an important
alert relating to G-size cylinders
Comments [1]
• Care should be taken when using G size cylinders with standard bull-nose
connectors and hospitals should use cylinders with built-in Schrader valves where
this is possible. Causing severe harm or death by administering the wrong gas, or
failure to administer any gas, through a line designated for Medical Gas Pipeline
Systems (MGPS) or through a line connected directly to a portable gas cylinder is a
‘never event’.
PATIENT SAFETY UPDATE JUNE 2014
Misconnections and an important
alert relating to G-size cylinders
Comments [2]
• The MHRA released a medical device alert in 2010 in response to reports of
incorrect setting and misconnections with the auxiliary common gas outlet available
on GE anaesthetic machines.1 Anaesthetists are also reminded of the AAGBI safety
guidance “Checking Anaesthetic Equipment” published in 2012 that advises a check
of patient circuit prior to the start of every case.2
• All incidents relating, or potentially related to, medical devices should be reported
to the Medicines and Healthcare products Regulatory Agency using their on line
facility.3 This ensures that any recurring incidents are collated and investigated
appropriately and that advice and recommendations can be cascaded as necessary.
PATIENT SAFETY UPDATE JUNE 2014
Misconnections and an important
alert relating to G-size cylinders
Reading
1. MHRA. Medical Device Alert (MDA/2011/108): Anaesthetic machine- Auxiliary Common Gas
Outlet, All Aestiva, Aisys, Aespire and Avance anaesthetic machines manufactured by GE
Healthcare. 01 December 2011. Available: http://www.mhra.gov.uk/home/groups/dtsbs/documents/medicaldevicealert/con137669.pdf
2. AAGBI. Guidelines: Checking Anaesthetic equipment. 2012. Available:
http://www.aagbi.org/sites/default/files/checking_anaesthetic_equipment_2012.pdf
3. MHRA. Reporting Adverse Incidents involving medical devices (webpage). Available:
http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/Devices/index.htm
PATIENT SAFETY UPDATE JUNE 2014
Serious complications of routine
clinical procedures
Incident Report [1]
• Patient admitted with tentative diagnosis of tension pneumothorax….Two attempts
made to insert an intercostal chest drain resulting in incorrect placement of both
drains - one subcutaneous and the second within the lung parenchyma…not
identified for several days. The patient deteriorated as a result of this placement…
The initial diagnosis was incorrect but was never challenged... placing a drain
should have been done by blunt dissection rather than Seldinger approach.
PATIENT SAFETY UPDATE JUNE 2014
Serious complications of routine
clinical procedures
Incident Report [2]
• Emergency patient for hip washout… left antecubital fossa cannula in situ, had been
receiving IV fluids on ward. Cannula flushed with saline, propofol used for induction
of anaesthesia - pain ++. Considered possibility of intra - arterial cannula. New
venous cannula inserted. Samples taken from both cannulae for blood gases. Left
antecubital fossa, clearly an arterial sample (pO2 32.7 versus pO2 15.9 from sample
from right cannula).
PATIENT SAFETY UPDATE JUNE 2014
Serious complications of routine
clinical procedures
Comment
• A patient safety alert, “Chest drains: risks associated with the insertion of chest
drains”, was released by the NPSA regarding the potential for patient harm when
inserting chest drains.1 Excellent guidance has also been published by the British
Thoracic Society.2 Regular training in skill-based emergency procedures is
encouraged for all anaesthetists.
• Inadvertent arterial cannulation is a recognised complication of cannulation of veins
in the antecubital fossa, particularly in children.3 Injection into a misplaced cannula
may be more likely if the cannula was sited previously by another individual. An
update on extravasation and inadvertent arterial administration of drugs is available
in a recent RCoA continuing education publication, “Extravasation injuries and
accidental intra-arterial injection”.4
PATIENT SAFETY UPDATE JUNE 2014
Serious complications of routine
clinical procedures
Reading
1. NPSA. Rapid Response Report (NPSA/2008/RRR003): Risks of Chest Drain Insertion.
15 May 2008. Available:
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60284&type=
full&servicetype=Attachment
2. D Laws et al. BTS guidelines for insertion of chest drains. Thorax 2003; 58 (Suppl II):
ii53 – ii59
3. P. Lirk et al Unintentional arterial puncture during cephalic vein cannulation: case
report and anatomical study British Journal of Anaesthesia 2004; 92 (5): 740 – 2
4. Lake, C; Beecroft, CL. Extravasation injuries and accidental intra-arterial injection.
Continuing Education in Anaesthesia, Critical Care and Pain 2010; 10 (4): 109-113
Available: http://ceaccp.oxfordjournals.org/content/10/4/109.full.pdf
PATIENT SAFETY UPDATE JUNE 2014
Monitoring during patient transfer
Incident report
• Patient transferred from medical assessment unit to ITU for monitoring, on arrival
the patient was unresponsive… it was noted that the patient was not connected to a
monitor for transfer… it was found that the lady was in pulseless electrical activity.
Arrest call made and resuscitation commenced…
Comment
• Transport of patients either within hospital or between sites is common; the staffing
and monitoring requirements should be considered in all cases. Guidance is
provided in the AAGBI publications1,2, Interhospital Transfer and Recommendations
for the Safe Transfer of Patients with Brain Injury and also in the Intensive Care
Society guidelines, Transport of Critically Ill Adults (2011).3
PATIENT SAFETY UPDATE JUNE 2014
Monitoring during patient transfer
Reading
1. AAGBI. Safety Guideline: Interhospital Transfer. February 2009. Available:
http://www.aagbi.org/sites/default/files/interhospital09.pdf
2. AAGBI. Recommendations for the Safe Transfer of Patients with Brain Injury. May
2006. http://www.aagbi.org/sites/default/files/braininjury.pdf
3. Intensive Care Society. Transport of Critically Ill Adults (3rd Ed). 2011. Available:
http://www.ics.ac.uk/EasysiteWeb/getresource.axd?AssetID=482&type=full&servic
etype=Attachment
PATIENT SAFETY UPDATE JUNE 2014
Errors associated with (assessment
of) the medical record
Incident report [1-3]
• Patient pre-assessed on the ward prior to being weighed. Came down to theatre
with weight of 10.5 kg. Child 3 years old and weighed 14.5 kg in January. Father told
staff weight was incorrect. This patient was brought to theatre with another
patients notes from the same ward - different name, age and sex ...
• Incorrect CT scan report in patients notes… detected before ' bad news ' broken to
family or treatment limitation decisions taken.
• Child assessed for surgery... it was not possible to access all the information relevant
to the patient from the electronic patient record. Some information was
handwritten in the patient record (undated)… the results from the multidisciplinary
team meeting were not recorded in the ICU electronic record... it is difficult to obtain
a clear picture of the patient history and the decision - making process. This is not an
isolated case in the hospital.
PATIENT SAFETY UPDATE JUNE 2014
Errors associated with (assessment
of) the medical record
Incident report [4-5]
• Patient for laparotomy due to bowel perforation... in-patient on medical ward with
CVA. Patient reported being on lisinopril only... drug card not reviewed… no report of
anticoagulant use when consulting with surgeon earlier. Clotting not done… to be
performed in theatre after arterial line insertion. Review of drug card in theatre prior
to antibiotic administration, discovered patient on warfarin after arterial and central
line insertion but pre knife-to-skin … last dose day previous. INR 4.7. Surgery
delayed… octaplex given… phoned by haematology lab… patient has atypical
antibodies… no locally available blood for patient. On review last INR done 3 days
previous. Group and save / crossmatch not done prior to need for surgery. Patient
stable and no identifiable harm due to surgical delay. Anaesthetist in a hurry and
interrupted for advice on more than one occasion during assessment.
PATIENT SAFETY UPDATE JUNE 2014
Errors associated with (assessment
of) the medical record
Incident report [5]
• A patient with a history of MI and angina attended pre op clinic and appears not to
have been referred for anaesthetic assessment as requested by Cardiology. Patient
proceeded to theatre and died one day post surgery.
PATIENT SAFETY UPDATE JUNE 2014
Errors associated with (assessment
of) the medical record
Comment
• These cases highlight situations where errors associated with the medical record
may be the root cause of potential or actual patient harm. The transition from
paper-based records to electronic systems may lead to new challenges, particularly
for anaesthetists who need to make a comprehensive risk assessment of the patient
in an increasingly time-pressured environment. Take care to give yourself adequate
time to assess all the available information; frequent interruptions are often the
cause of serious errors in healthcare.1-5
PATIENT SAFETY UPDATE JUNE 2014
Errors associated with (assessment
of) the medical record
Reading [1]
1. University of Aberdeen, Scottish Clinical Stimulation Centre. Anaesthetists’ Nontechnical Skills (ANTS) System Handbook v.1.0: Framework for Observing and Rating
Anaesthetists’ Non-technical Skills. June 2012. Available:
http://www.abdn.ac.uk/iprc/uploads/files/ANTS%20Handbook%202012.pdf
2. Lawton R et al. Development of an evidence-based framework of factors
contributing to patient safety incidents in hospital settings: a systematic review
British Medical Journal Qual Saf 2012. Available:
http://qualitysafety.bmj.com/content/early/2012/03/14/bmjqs-2011000443.full.pdf+html
PATIENT SAFETY UPDATE JUNE 2014
Errors associated with (assessment
of) the medical record
Reading [2]
3. Reason J. Understanding adverse events: human factors Quality in Health Care
1995;4:80-89 http://qualitysafety.bmj.com/content/4/2/80.full.pdf+html
4. Health and Safety Executive. Leadership and workier involvement toolkit: Knowing
what is going on around you (situational awareness). Available:
http://www.hse.gov.uk/construction/lwit/assets/downloads/situationalawareness.pdf
5. AAGBI. Pre-operative Assessment and Patient Preparation The Role of the
Anaesthetist. 2010. Available:
http://www.aagbi.org/sites/default/files/preop2010.pdf
PATIENT SAFETY UPDATE JUNE 2014
Surviving Sepsis
Incident report
• Patient with significant co-morbidities listed for urgent drainage of massive acuteon-chronic thigh abscess. Spinal anaesthetic. Difficult venous access. Difficulty
monitoring NIBP requiring multiple cuffs. 3L pus drained. Prolonged PACU stay with
difficulty establishing patient status. Persistent tachycardia but patient remained
very “well ". Fluctuating BP but difficulty establishing whether BP fluctuated due to
inappropriate cuff size or real measurements. Low BP readings were at odds with
the rest of the clinical picture, although repeated fluid challenges made no
difference to haemodynamics. After approx 2-3 hours, decision to transfer to HDU
and further monitoring commenced (Art line / CVC etc). At this stage it became
apparent that the BP was correct and the patient’s clinical picture was at odds with
the clinical scenario (rapidly deteriorating sepsis). Transferred to HDU but died later.
PATIENT SAFETY UPDATE JUNE 2014
Surviving Sepsis
Comment
• The Surviving Sepsis Campaign states that recognition of sepsis is the first step in
management of the septic shock.1 In a recent Parliamentary Ombudsman report2
failures in clinical care relating to sepsis included inadequate history-taking, lack of
accurate recognition of the severity of the illness and inadequate physiological
monitoring of vital signs.
• NCEPOD are currently undertaking a study to identify and explore avoidable and
remediable factors in the process of care for patients with known or suspected
sepsis. Publication of the results is expected in November 2015.3
PATIENT SAFETY UPDATE JUNE 2014
Surviving Sepsis
Reading
1. Dellinger, RD et.al. Surviving Sepsis Campaign: International Guidelines for the
Management of Severe Sepsis and Septic Shock 2012 Critical Care Medicine
February 2013; 43 (2). Available: http://www.sccm.org/Documents/SSCGuidelines.pdf
2. Parliamentary and Health Science Ombudsman. Time to act: Severe sepsis: Rapid
diagnosis and treatment saves lives. TSS 2013. Available:
http://www.ombudsman.org.uk/__data/assets/pdf_file/0004/22666/FINAL_Sepsis
_Report_web.pdf
3. NCEPOD. Sepsis study (webpage): http://www.ncepod.org.uk/sepsis.htm
PATIENT SAFETY UPDATE JUNE 2014
Regular reminders of National
Audit Projects
Incident report [1]
• Patient underwent an emergency laparotomy on the CEPOD list, a thoracic epidural
catheter was placed after induction of general anaesthesia... on awakening from
surgery the patient showed some features suggestive of a high block with weakness
in the legs and some other neurological symptoms… after negative aspiration the
catheter was removed… switched to pain management with a PCA… the patient was
complaining of hand weakness and showed clear signs of ongoing neurological
deficit including facial nerve involvement… a CT head showed no abnormality… an
MRI of the spinal cord was then arranged... showed evidence of widespread myelitis
of the cervical and thoracic cord.
PATIENT SAFETY UPDATE JUNE 2014
Regular reminders of National
Audit Projects
Incident report [2]
• Patient returned to critical care post tracheostomy… doctor handed over patient has
adjustable flange tube when it was not. Large leak noted with cuff pressure
increased to 60 cm. Patient deteriorated after rolling, lowest sats 28%. Intubated by
doctor and CPR done when patient lost cardiac output… patient has a DNAR signed
form. When doctor removed the tracheostomy tube he said it did not appear to be
in the right place. Patient was confirmed dead.
PATIENT SAFETY UPDATE JUNE 2014
Regular reminders of National
Audit Projects
Incident report [3]
• Attempted change of tracheostomy tube in morbidly obese patient… hypoxic cardiac
arrest and death. Indication - progressive massive surgical emphysema and
tracheostomy cuff leak. As advised by ENT consultant, trache change over a bougie
was attempted. The patient was adequately pre oxygenated, sedated and paralysed.
Grade of intubation known - easy. Insertion of a new tracheostomy tube failed…
procedure abandoned in favour or endotracheal intubation. Size 8 oral tube inserted
through vocal cords easily but got stuck and unable to advance further. Unable to
ventilate patient… changed for size 7 oral endotracheal tube over a bougie… patient
was very hypoxic. Unable to improve saturations despite confirming bilateral air
entry. Drop in blood pressure, poor arterial trace and bradycardia - CPR commenced
… decision to discontinue resuscitation taken.
PATIENT SAFETY UPDATE JUNE 2014
Regular reminders of National
Audit
Projects
Comments
• On-going reports to the NRLS of events with relation to the National Audit Project
topics (NAP3 major complications of central neuraxial block and NAP4 major
complications of airway management) highlight their importance and significance in
the day-to-day practice of anaesthesia. By continuing to highlight these adverse
events in the Patient Safety Updates, they retain a prominence in the reflective
reading of clinicians.
• The National Tracheostomy Safety Project provides guidance on the management of
tracheostomy and laryngectomy airway emergencies1. The National Confidential
Enquiry into Patient Outcome and Death will publish the results of the HQIP
supported study aiming to “identify the remediable factors in the quality of care
provided to patients who undergo a tracheostomy”2.
PATIENT SAFETY UPDATE JUNE 2014
Regular reminders of National
Audit
Projects
Reading
1. McGrath BA et al Anaesthesia 2012 Sep;67(9):1025-41 Multidisciplinary guidelines
for the management of tracheostomy and laryngectomy airway emergencies.
2. NCEPOD. Tracheostomy care study (webpage):
http://www.ncepod.org.uk/trachy.htm
PATIENT SAFETY UPDATE JUNE 2014
Good practice
Incident report
• Patient had 4 loose teeth, needing GA for the procedure advised of the risk of teeth
being lost due to precarious condition. On induction prising mouth open with
fingers, tooth popped out. Tooth put in gallipot. Patient intubated without any
further incident.
Comments
Guidance on how to deal with dental trauma occurring during anaesthesia is available
via SALG1. Assess the tooth and mouth for appropriateness of immediate re-siting of
the tooth. If in doubt, store the tooth in saline or milk for later assessment.
Departments should develop local policies in conjunction with their maxillofacial
surgical colleagues to treat these incidents.
PATIENT SAFETY UPDATE JUNE 2014
Good practice
Reading
1. Safe Anaesthesia Liaison Group. Dental Trauma During Anaesthesia. Managing
Risks. Available: http://www.rcoa.ac.uk/system/files/CSQ-DentalTrauma.pdf
PATIENT SAFETY UPDATE JUNE 2014
What was reported
• 5,200 anaesthesia-related incidents were reported
eForm
• 14 incidents were reported using the anaesthetic eForm
• 12 of these were reported as ‘near miss’
• seven of these incidents reported via the eForm were reported to the NPSA
within one day
Local risk management systems
• 5,186 incidents were reported using local risk management systems (LRMS)
• 13% of these were reported as ‘near miss’
• 45% of incidents were reported via LRMS to the NPSA within 30 days
PATIENT SAFETY UPDATE JUNE 2014
Figure 1
Figure 1 shows the degree of harm incurred by patients within the anaesthetic specialty
during the period 1 January 2014 to 31 March 2013. All 11 deaths were reported though
LRMS.
PATIENT SAFETY UPDATE JUNE 2014
Figure 2
Figure 2 shows the
type of incidents
that occurred within
the anaesthetic
specialty that were
reported using
LRMS or the
anaesthetic eForm
for the period 1
October 2013 to 31
December 2013.The
categories were
determined at local
level.
PATIENT SAFETY UPDATE JUNE 2014
Please report incidents so they can be used for learning
• Use your local system
Or
• Use the anaesthesia eForm https://www.eforms.nrls.nhs.uk/asbreport/
PATIENT SAFETY UPDATE JUNE 2014