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Adverse Events In Anaesthetics

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by

Rhys Worgan

on 9 February 2013

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Transcript of Adverse Events In Anaesthetics

Events occur when…

Active human failure
+
Latent underlying condition
=
EVENT Adverse events in Anaesthesia Errors in Anaesthesia OWAM recommendations Our recommendations We have learned... The strategies in place for preventing adverse events Examples of adverse events in Anaesthesia Firstly, what exactly is anaesthesia? Introduce a mandatory reporting system for adverse events and specify near-misses Make full use of new NHS information systems to help staff access learning from adverse health care events and near misses Improve the quality and relevance of NHS investigations and inquiries Introduce a scheme for confidential reporting by staff of adverse events and near misses Identify and address specific categories of serious recurring adverse events Encourage a reporting and questioning culture Act to ensure that important lessons are implemented and consistently Introducing a single overall system for analyzing and disseminating lessons from adverse events and near misses Better use of existing sources of data on adverse events Undertake a programme of basic research into adverse healthcare events in NHS Rhys
Ali
Hamilton Prasanna
Syeda Insha
Cheryl What system is in place to report and learn from critical incidents ? In Scotland: National

Targeted four main areas in clinical care and promoted leadership Scottish Patient safety programme Accomplished:
Unified patient safety guidelines for healthcare professionals
Established a learning system

Established a more effective data system Targeting reporting culture

Analyses of reported incidents and formulates summary reports In Anaesthetics: World-wide: WHO surgical checklist Scotland England and Wales SASM Reporting systems differ between hospitals and NHS boards 2 forms:
local reporting form
Anaesthetic E-form

SALG Anaesthetists are responsible for pain control, sedation and ensuring the patient remains stable in the pre, intra and post-operative periods.
Biggest hospital speciality who in many cases work with a dedicated nurses. No such thing as a general anaesthetist anymore; acute sub-specialities include… Cardiac, Thoracic, Neuro, Plastics, Paediatrics, Obstetrics, trauma and A&E.
Also opportunities in chronic pain management and the Intensive Care Unit.
To reach consultant level requires a minimum of 14 years of training and requires completion of the FRCA exam and CCT.
Anaesthetic trainees receive more supervision as it would be unacceptable to have a surgical death without senior anaesthetics input. Incidence of errors are no higher than elsewhere, however there is potential for major mistakes leaving people severely debilitated or even causing death (high associated cost).
Reflected by previously expensive medical insurance indemnity rates.
Improvements (airway management) have brought this in line with other specialities. Medical management includes all aspects
of care Omission/ commission errors Error: The failure to complete a planned action as intended, or the use of an incorrect plan of action to achieve a given aim.
Adverse event: An injury related to medical management, in contrast to complications of disease .
Near miss: A situation in which an error(s) fails to develop further, irrespective of compensating action being taken, thus preventing harm. What is… CIS in any specialty hard to quantify as the only way to get a number is via reporting systems or via observation in hospitals:

12 606 reports between January 2004 to February 2006 to NRLS

3913 anesthesia related incidents reported in the space of 3 months in 2012 to the NRLS

Of those, less than 2% is reported with the E-Form recommended by RCoA in Wales and England

Scotland no figures could be found as Datix data is not published

SASM: 814 cases involve anesthesia but at the end of the reviewing process only 85 cases were linked to anesthesia

A Hong Kong teaching hospital reported 125 critical incidents from a total of 16379 anesthetics performed How Often Do Critical Incidents Occur? Adverse Event! BLUNT END Technical/ organisational Skill, knowledge or rule-based James Reason
Latent Error: Delayed consequences of technical and organizational actions and decisions(blunt end).
Active Error: ‘unsafe acts’ committed by those in direct contact with the human-system interface (sharp end). Types of Errors Latent
Conditions Active Error Event James Reasons classification and examples of Active errors in Anaesthesia Re-attachment of partially used IV fluid bag
Silencing monitor alarms
Anaesthetist eating crisps in scrub area No proper history taken or allergies assessed
IV solution injected subcutaneous
Turning off machine at wrong time Attempted use of nerve locator in patient who had been given neuromuscular blocking agents
Local anaesthetic infusion nearly connected to IV cannula Administering wrong drug or to the wrong patient
Forgetting to see a patient or an appointment Communication problems (Anaesthetist sedated patient without informing other staff present, Surgeons pulled patient down table without first informing anaesthetist, patient not seen by anaesthetist before operation…) Examples of Latent errors in Anaesthesia

Device faults (alarm, screen, ventilator failures, …), bad design (connectors too easy to accidentally disconnect, alarms that could be disabled) or equipment not available (ultrasound, pulse meter…) Organisational problems (order of operating list changed, Unexpected⁄ unchecked admission, No assistant in the case of an emergency…) ‘Swiss cheese’ model of Accident causation The Incident Reporting Pathway Datix form is most common

Contributes information at a national level

Attributable to whoever submitted it

Dr X : “needs to be attributable”, “robust”, “straightforward” but “time consuming”.

Dr Y : “too remote”, “rarely received feedback” E-Form Most hospitals also have an internal reporting form

Collected by a nominated consulatant and used to provide feedback and learning on a local scale. Local Reporting Form 14 NHS boards in Scotland

Reporting protocol varies between boards

Health Improvement Scotland is responsible for identifying and disseminating information on adverse events.

The Medicines and Healthcare Products Regulatory Agency coordinates information across the UK.

“There is also no systematic mechanism for shared-learning to take place throughout NHSScotland”


[Building a national approach to learning from adverse events through reporting and review: A consultation paper - January 2013 Who oversees incident reporting? Part of NPSA

A portal to report any anaesthesia related incidents

Involves the safe Anaesthesia Liaison Group (SALG) Anaesthetic E-form
(in England and wales) Their Gaps: unified national reporting system for anaesthesia-related incidents A unified complaints system 9 year old boy admitted to hospital after a bike accident

Operation to reattach finger

Tony died as a result of lack of oxygen to the brain

Cause later determined to be a disposable cap in PBC Tony Clowes . A linked police investigation following a number
of incidents

. As a result 227 further incidents
were reported

. 85 cases assessed
52 soft incidents
5 Hard incidents
28 Other incidents Operation Orcadian . Occlusion of the PBC

. Failure to identify blocked component

. Identification of blocked PBCs as cause of O2 supply
obstruction

. Failure to supply oxygen by completely independent means Operation Orcadian . Tethering of caps/brightly coloured

. Packaging new/cleaned PBC components

. Attachment of AAGBI ‘Checking anaesthetic
equipment’

. Alternative means of ventilation always immediately
available Operation Orcadian . Royal college training in
-Recognising instances of ‘difficulty with ventilation’
-Identification of the problems origin
-Implementing effective recovery plans

. Royal college to assess machine checking procedures

. Vetting of staff

. Security access to anaesthetic areas Operation Orcadian Operation Orcadian NHS Territorial Boards A system to disseminate lessons learned from data reported using local reporting systems Data needs to be systematically and consistently analysed, compiled and disseminated into lessons that can be accessed by health professionals Clearer guidelines regarding critical incident reporting should be given Greater awareness of adverse events and greater emphasis on reducing non-fatal adverse events Spot checks into theatres A mobile application for reporting Risk of mortality in anaesthetic has reduced over the years Break down barriers formed by a power hierarchy Our references References/resources used for our presentation

What is Anaesthetics?
Dr.Z interview
NHS careers/ anaesthetics http://www.nhscareers.nhs.uk/explore-by-career/doctors/careers-in-medicine/anaesthetics/
Royal college of Anaesthetists http://www.rcoa.ac.uk/careers-and-training/considering-career-anaesthesia

Areas of Error generation
Organization with a memory
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4065083
Patient Safety Analysis Training
http://dkv.columbia.edu/demo/medical_errors_reporting/site/index.html
National Reporting and Learning System (NRLS), NHS, 2010 National Patient Safety AgencyPowered by Easysite
http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/
Clinical governance Educational Resources, NHS Scotland, 2007
http://www.clinicalgovernance.scot.nhs.uk/section5/erros.asp
James Reason , Safety culture, 1998
NRLS, How seriously harmed are patients ?, Section 2,Quarterly data summaries, 2008- 2009
http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/
http://images.google.co.uk/

Examples and measures put in place of prevention
Protecting the breathing circuit in anaesthesia, May 2004,
http://www.frca.co.uk/documents/Protecting%20the%20PBC.pdf Measures in place to prevent adverse events and gaps within them
www.rcoa.ac.uk/system/files/CSQ-PS-PSU-JULY2012_0.pdf

Scottish Patient Safety Programme
http://www.knowledge.scot.nhs.uk/media/CLT/ResourceUploads/1009304/Health%20Affairs%20Scotland.pdf
http://www.scottishpatientsafetyprogramme.scot.nhs.uk
http://www.clinicalgovernance.scot.nhs.uk/section5/introduction.asp

WHO surgical safety checklist
http://www.scottishpatientsafetyprogramme.scot.nhs.uk/docs/WHO%20Surgical%20Safety%20Checklist.pdf


Set out the system at work
http://www.clinicalgovernance.scot.nhs.uk/section5/learn.asp
http://www.healthcareimprovementscotland.org/programmes/governance_and_assurance/management_of_adverse_events/adverse_events_framework.aspx
https://www.eforms.npsa.nhs.uk/asbreport/

Interviews
Dr X: Consultant anaesthetist based in a large Glasgow hospital
Dr Y: Consultant anaesthetist based in a large Glasgow hospital
Dr Z: Consultant anaesthetist based in a large Northern Irish hospital Human error is inevitable. The only way to move forward from our mistakes is to record them and implement changes.
Latent conditions and the potential for system error are ever-present but it is through our actions of reporting errors that we can maximise improvement.
Denis likes planes.
Doctors are just as error prone as the public, everyone should question those around them if in doubt.
Be confident enough step outside the hierarchy and raise concerns.
Change in organisations is extremely difficult to implement (from blame culture -> safety culture)
We now know the correct protocol for reporting when things go wrong.
The responsibility for patient safety lies with everyone therefore no one should get complacent.
Group processes require communication, cooperation, efficiency and trust.
Anaesthetics is a difficult word to say. Thanks to... Any Questions?
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