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Dr Isabeau Walker
AAGBI Council
Chair of Safety
Linkman Conference September 2011
Safety Committee Update
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2010/11: an overview
DH
NPSA
MHRA
Safe Anaesthesia Liaison Group
Patient Safety Updates
AAGBI Statements
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DH Never events
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DH Never events
Serious, largely preventable patient safetyincidents 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-containingsolutions
Maternal death due to post partum haemorrhage
after elective Caesarean section
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Never events policy 2011/12 Expanded list of never
events
Cost recovery
If providers deliver carethat is of poor quality the
option should exist to
ensure that the tax payer
does not have to pay for
that care
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Never events policy 2011/12 Intravenous administration
of epidural medication
Wrong gas administered
Failure to monitor andrespond to oxygen
saturation
Overdose of midazolam
during conscious sedation
Opioid overdose of an
opioid-nave patient
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NPSA
Review of DH Arms Length Bodies June 2010
Formal closure by April 2012
Functions of NRLSNHS Commissioning Board
Incidents must still be reported
Data sharing agreement between NRLS and
RCoA/AAGBI continued until December 2011
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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
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NPSA: Patient Safety Alerts
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Patient Safety Alert spinal
needles
Risk assessment
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NPSA: Signal alerts
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Signal alert shared ampoules
7/35 patients developed SIRS after GA with
propofol
100ml bottles spiked and shared between patients
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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
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MHRA
Medicines anddevices work and are
safe
Operate post-
marketingsurveillance for
incidents relating to
drugs and medical
devices
Medical device alerts
Drug safety updates
One liners
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MHRA: Medical Device Alerts
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Infection control in anaesthesia
Anaesthetic equipment
is a potential vector...
Single use equipmentshould be utilised where
appropriate
Laryngoscope handlesshould be
washed/disinfected/steri
lised (if suitable) after
every use
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Safe Anaesthesia Liaison Group
Core members: NPSA, RCoA, AAGBI
Advisory input individuals, institutions, spec
socs
Anaesthetic eForm
Quarterly analysis of incident reports
Safety campaigns
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Update September
2011:
2990 incidents
79 via eForm
Treatment/procedure
Medical devices Medication
Implementation of
care and on-going
monitoring/review
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Examples of reported incidents
Equipment checksACGO
Vapourisers, CO2 absorber
Power supply
AMBU bag
Medication
Paracetamol
TIVA Treatment/procedure
Residual drugs
Motor block assd with epidural
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Wrong site blocks
Wrong site blockscommon:
Time delay between
sign-in and block
Covering of surgical
site marking
Distraction
Nottingham University
SB4YB campaign:
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AAGBI statements
Capnography
Sedation in children and young people
Neuraxial connector risk assessment
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Capnography statement May
2011
Amendment tostandards for
monitoring
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Capnography statement May
2011
Continuouscapnography should
be used for:
All anaesthetised or
intubated patientsregardless of location
All patients
undergoing moderate
or deep sedation
All patients
undergoing advanced
life support
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NICE Guidelines for Sedation in
Children and Young People
Joint statement RCoAand AAGBI
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NICE Guidelines for Sedation in
Children and Young People
Use of anaestheticagents by healthcare
workers
Training in airway
rescue skills for deepsedation
Venue for sedation
specialist centre vs
DGH vs communitypractice
Multidisciplinary
Sedation Committees
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How we contact you....
SALG Patient Safety
Updates
e-Newsletter
AAGBI website
News items Safety section
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Please contact us!
[email protected]
mailto:[email protected]:[email protected]
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Summary
Never events framework
Incident reporting
Treatment/procedures
Medical devices
Medication
Capnography statement Sedation
Neuraxial connector risk assessment
