Anaesthetists and other clinical staff throughout England and Wales will soon have access to a specially designed system where they can report patient safety incidents and “near misses”. The system has been jointly developed by the National Patient Safety Agency (NPSA), Royal College of Anaesthetists (RCoA) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI).
The “e-form” reporting system has been piloted in thirteen NHS Ttrusts across England and Wales since May this year. At the Association of Perioperative Practice (AfPP) congress, the results of the pilot were presented by Joan Russell, head of anaesthesia and surgery, NPSA. During the first four months, a total of 149 incidents were reported. These were all reviewed within 24 hours of receipt by the NPSA. If any incidents were identified as having potential cause for concern, they were brought to the attention of a consultant anaesthetist from the Royal College of Anaesthetists for further opinion. This consultant was contacted on a weekly basis to give an overview of the incidents reported during that week, in line with the NPSA’s data sharing protocol. (No information about the Trust is disclosed).
Three incidents resulted in severe harm, three in death, 21 in moderate harm, and 69 in either no or low harm. Examples of drug issues included: non-adherence to prescribed insulin regime; adverse reaction to Gelofusin; anaphylaxis to muscle relaxant; antibiotics; induction agent; overdose of antibiotics; wrong volatile agent selected; inadequate reversal; epidural block inadequate or wrong drug selected when distracted. There were 21 incidents attributed to such issues.
Examples of equipment issues included failure of capnograph; fibre optic intubation equipment not available; wrong vascular equipment selected; failure of IV pump; displacement of ET tube during transfer; disconnection of ventilation tubing during procedure when patient remote from machine; inadequate IV equipment for bariatric patient and anaesthetic machine not checked by a senoir consultant. There were 34 incidents of this type. Incidents relating to anaesthetic or other clinical problems, included unexpected failed intubations; laryngospasm; aspiration/ regurgitation; inadequate preop assessment; malignant hyperpyrexia and tooth displacement. Fifty-six incidents occurred for this category. Other incidents, totalling 38, covered issues such as portering; non-availability of ITU HDU beds; theatre too hot to work in; communication failures on patient arrival; correct site surgerymarking problems; delay in blood transfusion and non-availability of notes.
Speaking of the specialty-based anaesthetic reporting system pilot, Martin Fletcher, chief executive of the NPSA said: “By continuing to promote better reporting – and making sure we respond to what we learn – we will establish a more complete picture of the patient safety issues we face and ensure that safety priorities focus on where action is most needed.”
