Safety Committee Update

Dr Isabeau Walker AAGBI Council Chair of Safety Linkman Conference September 2011

2010/11: an overview
DH

NPSA
MHRA Safe Anaesthesia Liaison Group
Patient Safety Updates

AAGBI Statements

DH Never events

DH Never events
Serious, largely preventable patient safety

incidents that should not occur if the available preventative measures have been implemented by healthcare providers
Wrong site surgery
Retained foreign object post-operation Maladministration of potassium-containing

solutions Maternal death due to post partum haemorrhage after elective Caesarean section

Never events policy 2011/12

Expanded list of never

events
Cost recovery
If providers deliver care

that is of poor quality the option should exist to ensure that the tax payer does not have to pay for that care

Never events policy 2011/12

Intravenous administration

of epidural medication
Wrong gas administered Failure to monitor and

respond to oxygen saturation

Overdose of midazolam

during conscious sedation

Opioid overdose of an

opioid-nave patient

NPSA
Review of DH Arms Length Bodies June 2010
Formal closure by April 2012

Functions of NRLS NHS Commissioning Board

Incidents must still be reported Data sharing agreement between NRLS and

RCoA/AAGBI continued until December 2011

Confidential enquiries into maternal deaths

Maternal and newborn outcome review July 2011
Confidential enquiries to continue... Healthcare Quality Improvement Partnership New interim arrangements... Maternal and Perinatal Mortality Notifications

NPSA: Patient Safety Alerts

Patient Safety Alert spinal needles

Risk assessment

NPSA: Signal alerts

Signal alert shared ampoules

7/35 patients developed SIRS after GA with

propofol 100ml bottles spiked and shared between patients

Signal alert - sedation

650 reports/year of adverse events from sedation

34 deaths or severe harm (2003-2010)

Isolated areas, junior staff Lack of availability of anaesthesia/ICU staff or

failure to ask for them

NHS organisations to consider reviewing policies

MHRA
Medicines and

devices work and are safe

Operate post-

marketing surveillance for incidents relating to drugs and medical devices

Medical device alerts Drug safety updates

One liners

MHRA: Medical Device Alerts

Infection control in anaesthesia

Anaesthetic equipment

is a potential vector...
Single use equipment

should be utilised where appropriate

Laryngoscope handles

should be washed/disinfected/steri lised (if suitable) after every use

Safe Anaesthesia Liaison Group

Core members: NPSA, RCoA, AAGBI Advisory input individuals, institutions, spec

socs
Anaesthetic eForm Quarterly analysis of incident reports Safety campaigns

Update September 2011: 2990 incidents

79 via eForm

Treatment/procedure Medical devices

Medication
Implementation of

care and on-going monitoring/review

Examples of reported incidents

Equipment checks
ACGO Vapourisers, CO2 absorber Power supply AMBU bag

Medication
Paracetamol TIVA

Treatment/procedure
Residual drugs Motor block assd with epidural

Wrong site blocks

Wrong site blocks

common:
Time delay between

sign-in and block Covering of surgical site marking Distraction

Nottingham University

SB4YB campaign:

AAGBI statements
Capnography

Sedation in children and young people

Neuraxial connector risk assessment

Capnography statement May 2011

Amendment to

standards for monitoring

Capnography statement May 2011

Continuous capnography should be used for: All anaesthetised or intubated patients regardless of location All patients undergoing moderate or deep sedation All patients undergoing advanced life support

NICE Guidelines for Sedation in Children and Young People

Joint statement RCoA

and AAGBI

NICE Guidelines for Sedation in Children and Young People

Use of anaesthetic

agents by healthcare workers Training in airway rescue skills for deep sedation Venue for sedation specialist centre vs DGH vs community practice
Multidisciplinary

Sedation Committees

How we contact you....

SALG Patient Safety

Updates
e-Newsletter AAGBI website
News items Safety section

Please contact us!

secretariat@aagbi.org

Summary
Never events framework Incident reporting
Treatment/procedures Medical devices Medication

Capnography statement

Sedation
Neuraxial connector risk assessment