Dr Isabeau Walker AAGBI Council Chair of Safety Linkman Conference September 2011 Safety Committee...
28
Dr Isabeau Walker AAGBI Council Chair of Safety Linkman Conference September 2011 Safety Committee Update
-
Upload
hilda-mckinney -
Category
Documents
-
view
216 -
download
0
Transcript of Dr Isabeau Walker AAGBI Council Chair of Safety Linkman Conference September 2011 Safety Committee...
Dr Isabeau WalkerAAGBI CouncilChair of Safety
Linkman Conference September 2011
Safety Committee Update
2010/11: an overviewDHNPSAMHRA
Safe Anaesthesia Liaison GroupPatient 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 surgeryRetained foreign object post-operationMaladministration of potassium-containing
solutionsMaternal death due to post partum
haemorrhage after elective Caesarean section
Never events policy 2011/12Expanded 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-naïve patient
NPSA
Review of DH Arm’s Length Bodies June 2010Formal closure by April 2012
Functions of NRLS NHS Commissioning BoardIncidents must still be reportedData 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 staffLack 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 alertsDrug 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/sterilised (if suitable) after every use
Safe Anaesthesia Liaison Group
Core members: NPSA, RCoA, AAGBIAdvisory input – individuals, institutions,
spec socs
Anaesthetic eFormQuarterly analysis of incident reportsSafety campaigns
Update September 2011:
2990 incidents79 via eForm
Treatment/procedureMedical devicesMedicationImplementation of
care and on-going monitoring/review
Examples of reported incidentsEquipment checks
ACGOVapourisers, CO2 absorberPower supplyAMBU bag
MedicationParacetamolTIVA
Treatment/procedureResidual drugsMotor block assd with epidural
Wrong site blocksWrong site blocks
common:
Time delay between sign-in and block
Covering of surgical site marking
Distraction
Nottingham University SB4YB campaign:
AAGBI statementsCapnographySedation in children and young peopleNeuraxial connector risk assessment
Capnography statement May 2011Amendment to
standards for monitoring
Capnography statement May 2011Continuous 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 PeopleJoint 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 websiteNews itemsSafety section
Please contact [email protected]
Summary‘Never events’ framework
Incident reportingTreatment/proceduresMedical devicesMedication
Capnography statementSedationNeuraxial connector risk assessment
