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-naïve patient
NPSA
 Review of DH Arm’s 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