PSU Presentation JUNE2015

7/23/2019 PSU Presentation JUNE2015

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PATIENT SAFETY UPDATE JUNE 2015

This presentation should be used in on!untion "ith the#ull publiation$

Patient Safety Update including the summary of reportedincidents relating to anaesthesia1 January to 31 March2015.


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What is the Safe AnaesthesiaLiaison Group (SALG)?

A joint committee of the RCoA, AAGBI, national safetyoranisations, !RLS manaers, patients an" other oranisationsan" in"i#i"uals representin patient safety issues across the $%

SALG has a "ata sharin areement un"er &hich critical inci"ents

reporte" 'y hospitals to the !RLS are pro#i"e" for &i"er sharin

he atient Safety $p"ate is a *uarterly pu'lication &hich is themechanism for sharin reporte" "ata

his presentation pro#i"es a pr+cis of the atient Safety $p"ate forune -./0



3/28

Raise the pro1le of patient safety &ithin "epartments2

Learn from the e3perience of others2

$se the sli"es that you 1n" useful (there is no nee" to use themall)2

Sli"es shoul" 'e use" &ith the "etails in the full safety up"ate2

A"" information from your o&n "epartment2

4ee"'ac5 to SALG6rcoa2ac2u52

Why "iscuss the atient Safety$p"ate at 787?

mailto:[email protected]:[email protected]


4/28

9! :; SALGAG;!


5/28

9n the SALG Aen"aSA%& Sa#et' Initiati(e Sur(e'

SALG in#ites you to complete a short sur#ey &ith the aim ofmeasurin a&areness an" the impact of SALG communications2 We&oul" 'e particularly rateful if you coul" circulate this sur#ey&i"ely amon your colleaues2 =our ans&ers &ill help inform futureSALG communications2 lease complete to sur#ey 'y 1stJul') 2015

(https>&&&2sur#eymon5ey2comssalsur#ey)2

Patient Sa#et' *on#erene 2015

he annual SALG atient Safety Conference &ill 'e hel" on @th!o#em'er -./0 at hin5an5 (Birminham Science 7useum) in

Birminham2 here &ill also 'e an a'stract competition for traineeanaesthetists2 4or more information a'out e#ent reistration,proramme an" a'stract competition, please see>http>&&&2rcoa2ac2u5e"ucationan"e#entspatientsafetyconference2



6/28

9n the SALG Aen"aAA&+I position state,ent on the ad,inistration o#ontrolled dru-s b' anaesthetists

he AAGBI ha#e release" a position statement on thea"ministration of controlle" "rus 'y anaesthetists follo&in anamen"ment to the 7isuse of &&&2aa'i2orne&saa'ipositionstatementa"ministrationcontrolle""rusanaesthetistspatientuse2



7/28

L;AR!I!G 9I!S

4R97 R;9R; A ractical ool5it for Impro#ement InternetM2

/st e"2 -./ cite" -- 7ay -./0M2 A#aila'le from &&&2rcoa2ac2u5no"e/@K@-


9/28

Inident .eport$

Rapid sequence induction for EUA/management of persistent torrentialnosebleed. Post induction, delay in starting volatile anaesthetic agent leadingto accidental aareness. NAP ! protocols started and patient has been spo"ento three times post#op and referred to the clinical psychologist.

*o,,ents$

!A0(/) "emonstrate" that a&areness occurs most commonly in the "ynamicphases of anaesthesia> in"uction an" emerence an" nota'ly &hentransferrin from anaesthetic room to theatre, a perio" terme" the ap2 heauthors recommen"e" incorporatin a chec5 for this potential ap in "eli#eryof anaesthesia into the theatre safety chec5list2 his may 'e achie#e" in the$ime %ut part of the presurery chec52 !A0 also recommen"s use of anAnaesthesia A&areness ath&ay (-)2

Further .eadin-$/ !A0 Report, he !ational Institute of Aca"emic Anaesthesia InternetM2 -./0 cite" /E 7ay -./0M2

A#aila'le from> &&&2nationalau"itprojects2or2u5!A0report

- !A0, Anaesthesia A&areness ath&ay J he !ational Institute of Aca"emic Anaesthesia InternetM2-./0 cite" /E 7ay -./0M2

A#aila'le from> &&&2nationalau"itprojects2or2u5!A0AnaesthetiaA&arenessath&ay


!ational Au"it roject 0 (!A0)


10/28

Inident .eport$

&'( patient ith recently inserted tracheostomy rolled for ashing. )aturationprobe as not recording* monitor as alarming due to hypertension... patientrolled onto her bac"* audible noise li"e a cu+ lea" or upper airaysecretions... no obvious dislodgement... saturations ere -... ater0s circuitused as the patient as clearly not ventilating properly. hen 1r arrived the

patient as still saturating at -. As the tracheostomy as so ne, 1rdecided to orally intubate... patient desaturated to 2-. $he tracheostomy as

removed and the stoma occluded... patient as ventilated using the bag#valvemas". 3irst attempt to intubate4 di5cult to pass the bougie... patientdesaturated so as put bac" on the bag valve mas"... gelinserted...saturations then returned to normal range. )econd attempt tointubate # tube passed ithout bougie, di5cult

to see chest rising* some air entry heard but decreased air entry on left side.

)aturating ell. hilst being bagged, patient desaturated to appro6imately7! and then lost output, 'PR started* return of spontaneous circulation.'onsultant as then called. Patient no ventilating on - o6ygen, saturatingell. 'hest 6#ray shoed a left pneumothora6* inserted a chest drain. Repeatchest 6#ray shoed pneumothora6 had resolved. 'hest drain stopped singingand bubbling8 9loc"ed ith blood clot... inserted a ider bore chest drain.9ronchoscopy performed. 9lood visible in patients mouth* 7-mls aspirated on

subglottic suction. :continues on ne6t slide; PATIENT SAFETY UPDATE JUNE 2015

!ational Au"it roject @ (!A@)


11/28

Inident .eport /*ontinued$

9lood no visible in both nostrils and some blood in E$ tube... tidal volumesdropped, patient ventilated using the ater0s circuit, blood clots evident onsuction... Noradrenaline infusion running as hypotensive and increasingrequirements* &< trane6amic acid given... = units of 33P given.

*o,,ents$

!A@(/) hihlihte" the IC$ as a speci1c area of clinical practice &here air&ay"iDculties arose an" &here they &ere more li5ely to ha#e seriousconse*uences, inclu"in se#ere harm or "eath2 he report "escri'es a "iDcultcase that &as manae" &ell2 Interestinly, the report ma5es no mention ofcapnoraphy to con1rm en"otracheal intu'ation an" a"e*uate #entilation2!A@ state" that increasin the use of capnoraphy in IC7 &as the sinle stepthat ha" the potential to pre#ent the most "eaths2

Further .eadin-$/ Coo5 , Woo"all !, 4rer5 C2 !A@, ;3ecuti#e Summary InternetM2 /st e"2 Lon"onF -.// cite" /E 7ay

-./0M2

A#aila'le from &&&2rcoa2ac2u5system1lesCSO!A@;S2p"f


!ational Au"it roject @ (!A@)


12/28

Inident .eport$

$o days post boel resection. Epidural had been or"ing ell ith normalneurology and patient able to stand up ith physios the previous day. (oresigni>cant neuro de>cit in legs noted ne6t day. Epidural stopped pendingsitch to oral analgesia. 9loc" failed to recede after several hours. 9rought toattention of %bstetrics on#call anaesthetist ho then contacted me.

*o,,ents$!A(/) sho&e" that most C!S injury follo&e" the use of C!B in theperioperati#e perio" an" mostly after epi"ural 'loc5s2 he report alsosueste" that harm resulte" from a failure to reconise pro'lems an" "elay inrespon"in2 he 1nal recommen"ation of the report i"enti1e" a care 'un"le tosupport safe epi"ural care2 SALG has commissione" the e"itor of the !Areport to create a perioperati#e epi"ural chec5list, &hich shoul" 'e a#aila'le

for re#ie& in the ne3t fe& months2

Further .eadin-$/ Coo5 2 !A 7ajor Complications of Central !eura3ial Bloc5 in the $nite" %in"om InternetM2 /st e"2

Lon"onF -..E cite" /E 7ay -./0M2 A#aila'le from> &&&2rcoa2ac2u5system1lesCSO!A4ullP/2p"f


!ational Au"it roject (!A)


13/28

Inident .eport$

Prescription and administration of 'le6ane to a patient only ? hours afterneurosurgery.

*o,,ents$

;nsurin that patients ha#e their Q; ris5 assesse" an" manae" is anaccepte" part of the surical safety chec5list, an" is part of the share" team

un"erstan"in2 !IC;(/) ui"ance on "eep #enous throm'osis an"

pulmonary em'olism in a neurosurical population2@ Neurosurg -.//F//@(/)>@.@2


Balancin Ris5


14/28

Inident .eport 1$

Patient admitted ith shortness of breath. E6amined in AE 4 severepneumonia, metabolic acidosis, AB&. &$U and medical referral completed. &$Uconsultant recommended intubation and admission to &$U. $his did not occur,

patient stayed in AE, outreach revieed in clinical decision unit. Patientintubated and ta"en to &$U and died a fe hours later.

Inident .eport 2$

A patient as admitted by the medical team ith diabetic "etoacidosis, sepsisprobably secondary to pneumonia and episode of )


15/28

Inident .eport $

%ro#ma6illofacial revie of post#op head and nec" cancer patient admitted tothe unit earlier that morning... radial forearm free Fap to reconstruct the intra#oral de>cit* last revie >ve hours earlier* e6plained the patients history, thee6tent of the initial surgery and reasoning behind admission to &'U to thenurse concerned* covered protocol for Fap observations in %(3) patientsincluding colour, temp, te6ture, capillary re>ll and dopplering... discussed the

details of the post#operative instructions* the nurse informed me that this astheir >rst time loo"ing after a Fap but had support in the area to help them...suggested lo threshold to call regarding any concerns. Gater that morning theFap as clearly in a poor condition and had become completely congested.


!ontechnical s5ills> their contri'ution to failure toreconise an" failure to rescue the critically ill patient


16/28

*o,,ents$;nsurin that patients ha#e their Q; ris5 assesse" an" manae" is anaccepte" part of the surical safety chec5list, an" is part of the share" teamun"erstan"in2 !IC;(/) ui"ance on


17/28

Inident .eport 1$

After induction of anaesthesia* problems ventilating the patient* reaction tothe anaesthesia resulting in brittle bronchospasm... started a salbutamolinfusion hile investigating the cause. $he cause turned out to be ventilatorfailure rather than bronchospasm. $he machine as replaced. Patient then

positioned but became tachycardic and hypotensive ith E'H )$ segmentchanges* could not e6plain this or connect it to the earlier events so stopped

the salbutamol and called for a second opinion. )everal colleagues came tohelp* one colleague realised the miscalculation of salbutamol dose* patientreceived an overdose.

Inident .eport 2$

Patient for emergency caesarean section. Accidental intravenous inIection of

local anaesthetic. &mmediately recognised. $reated ith &ntralipid as per AAH9&Huidelines. Anaesthetised, baby delivered by emergency c/s uneventfully.(other remained haemodynamiclly stable.



18/28

*o,,ents$In a crisis, ma5in the "ianosis an" "eli#erin the correct treatment is "iDcultan" stressful2 Crisis chec5lists help manae unfamiliar situations, e22 acute'ronchospasm2(/) he AAGBIs Crisis Chec5list Wor5in party is "e#elopinemerency chec5lists for local "epartment a"aptation2


19/28

Further .eadin-$/ Arriaa A4 et al2 Simulation J 'ase" trial of surical crisis chec5lists2 N Engl @ (ed -./F K>-@-02- 7:RA, !:S ;nlan"2 atient Safety Alert> Impro#in me"ication error inci"ent reportin an" learnin

InternetM2 7arch -./@ cite" /E 7ay -./0M2 A#aila'le from> &&&2enlan"2nhs2u5&pcontentuploa"s-./@.psasupinfome"error2p"f

!:S ;nlan" atient Safety


20/28

Inident .eport 1$

Patient reported a Jhole0 in mouth after general anaesthesia :ith G(A; for"nee arthroscopy... patient had a small :appro6 !mm 6 !mm; hole in the rightside of the soft palate* had noticed a little blood in his mouth post op*apologised to the patient for the event and told him that revie by thema6illofacial team ould ta"e place* advised that surgical repair under HAas necessary. $he anaesthetist responsible reported that on emergence in

the recovery area the patient has regurgitated a little and had requiredsuctioning ith a Kan"auer suc"er. $he patient had also developedlaryngospasm. $he ma6illofacial consultant felt that the most li"ely cause ofthe trauma as from the Kan"auer suction.

Inident .eport 2$

Accidental iatrogenic intraoperative oesophageal perforation.


Iatroenic Injury


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*o,,ents$

In the ne&sletter of the American Society of Anesthesioloists there is a reporton the latest re#ie& of close" claims loo5in at air&ay complications 'et&een/EK. an" -.//2 Air&ay injuries accounte" for E//V of all close" claims ineach "eca"e, an" a'out onethir" of all air&ay claims are associate" &ith"iDcult intu'ation2 he oesophaus is the most common site of injury2 (/)

A comprehensi#e summary of iatroenic injury associate" &ith anaesthesia is

a#aila'le in the C;ACC2 (-)

Further .eadin-$/ Close" Claims Air&ay Injury Analysis Spotlihts ro'lems InternetM2 -./0 cite" -- 7ay -./0M2

Anesthesiology Nes &&&2anesthesioloyne&s2comQie&Article2asp3?"UClinicalAnesthesioloy8"Pi"U/8iUApril-./08iPi"U//K8aPi"U.E.-

- Contractor S, :ar"man 2 Injury "urin anaesthesia2 'EA''P -..F(-)>HJH.2


Iatroenic Injury


22/28

Inident .eport 1$

Patient found to have omepraLole infusing don the same port asnoradrenaline. %mepraLole 8 Pushing noradrenaline bac" don the line asblood noted to be bac" trac"ing. Patient0s blood pressure dropped to beteen!-#7- systolic and had a cardiac arrest. %ne cycle given and vial ofadrenaline given. 'ardiac output returned. 'PR stopped.

Inident .eport 2$

A central line as inserted in the &$U* 'MR as chec"ed although there is nodocumentation of this e6cept for the nurse0s notes. $he line as deemed safeto use. $here as no documentation of any central venous pressure reading

prior to the discovery that the central line as placed in the carotid artery. $heline as used to infuse noradrenaline, adrenaline, alfentanil, meropenem,

ranitidine, paracetamol and a couple of doses of $aLocin. $he patient0s rightupper limb as noted to be ischaemic ith no arterial pulses. $he incident asnoted in theatres by 1r ho noted the (AP of the arterial line as the same asthe pressure on the '


23/28

*o,,ents$

AntireXu3 #al#es shoul" 'e inserte" to a#oi" the ris5 of 'ac5 Xo& &hen"eli#erin multiple infusions2(/) !IC; ui"ance on the use of ultrasoun" for theinsertion of CQC is &ellaccepte" in practice2 Attachin the CQC to a pressuretrans"ucer an" #isualisin the #enous &a#eform prior to usin the line canenhance safety an" pro#i"e reassurance2(-)

Further .eadin-$/ %eay S, Callan"er C2 he safe use of infusion "e#ices2 'EA''P -..@F@()>K/JK02

http>ceaccp2o3for"journals2orcontent@K/2full2

- Gi'son 4, Bo"enham A2 7isplace" central #enous catheters> applie" anatomy an" practicalmanaement 9ritish @ournal Anaesthesia -./F

http>'ja2o3for"journals2orcontentearly-./.-.@'ja2aes@EH2full2p"fhtml2


Central Qenous Catheters aain


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I!CI


25/28

3hat "as reported,K- anaesthesiarelate" inci"ents &ere reporte"

eFor,4i#e inci"ents &ere reporte" usin the anaesthetic e4ormhree of these &ere reporte" as near miss%oal ris4 ,ana-e,ent s'ste,s.0H inci"ents &ere reporte" usin local ris5 manaementsystems (LR7S)/-V of these &ere reporte" as near miss



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3igure sho&s the "eree of harm incurre" 'y patients &ithin theanaesthetic specialty "urin the perio" / anuary / 7arch -./02 /K"eaths &ere reporte" thouh LR7S, an" none throuh the e4orm2

Fi-ure 1



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3igure ?sho&s thetype of

inci"entsthatoccurre"&ithin theanaestheticspecialtythat &erereporte"usin LR7Sor theanaesthetice4orm forthe perio" /anuary J /7arch -./02hecateories&ere"etermine"at localle#el2

Fi-ure 2



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Please report inidents so the' an be used #or

learnin-

$se your local system

9r

$se the anaesthesia e4ormhttps>&&&2eforms2nrls2nhs2u5as'report

https://www.eforms.nrls.nhs.uk/asbreport/https://www.eforms.nrls.nhs.uk/asbreport/

PSU Presentation JUNE2015

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