Dr Isabeau Walker AAGBI Council Chair of Safety Linkman Conference September 2011 Safety Committee Update

2010/11: an overview DH NPSA MHRA Safe Anaesthesia Liaison Group Patient Safety Updates AAGBI Statements

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 ( ) 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, CO 2 absorber Power supply AMBU bag Medication Paracetamol TIVA Treatment/procedure Residual drugs Motor block ass d 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!

Summary ‘Never events’ framework Incident reporting Treatment/procedures Medical devices Medication Capnography statement Sedation Neuraxial connector risk assessment