Memorandum by the Royal College of Anaesthetists
1. In constructing this response we have
noted the Health Committee brief and, as requested, provided short
and individual responses to questionsidentifying specific
areas of involvement of the College with regard to patient safety.
This submission is representative of the organisation and not
of any one individual. Where stated, and unless otherwise indicated,
"anaesthesia" should be considered to include all three
areas of responsibility for the Collegeanaesthesia, critical
care and pain management.
2. The Royal College of Anaesthetists was
granted a Charter
by Her Majesty the Queen in March 1992 and the right to use the
title "Royal". In accordance with the Charter, and fundamental
to our operations, has been the drive to advance patient safety
through the education and training of medical practitioners, the
promotion of study and research in anaesthesia, and to educate
the general public in all matters relating to anaesthesia.
3. To this end we have initiated competence-based
training for anaesthetists, linked this to core topics for the
further development of the qualified anaesthetist and instigated
a continuous cycle of review and revision to ensure anaesthetists
remain current in all relevant areas of their practice. Anaesthesia
is a rapidly developing medical specialty, particularly in the
areas of drugs and equipment used for direct patient care. It
is in these two key areas that the College has been particularly
active in identifying and reducing risks and so improving patient
4. Noting that two thirds of all patients
who enter the secondary care environment will come into contact
with an anaesthetist at some stage, the College has endeavoured
to ensure that all safety initiatives develop through partnerships.
We are particularly enthusiastic in combining safety advances
and initiatives with our hospital colleagues eg surgeons, nurses,
Operating Department Practitioners (ODPs) and other healthcare
professionals. Beyond the direct environment of the anaesthesia
team we continue to develop initiatives at the national level
with patient organisations, the Department of Health (DH) and
various key "arm's length bodies" of the UK National
Health Service (NHS).
5. The Royal College of Anaesthetists (RCoA)
recognises that there is no room for complacency in the area of
patient safety. We strive to obtain all available information
on areas of harm or potential harm to patients under the care
of anaesthetists and have interrogated the database of the National
Patient Safety Agency (NPSA) to this end. As a result we have
worked with colleagues at the NPSA to trial a specialty specific
reporting system, as part of their National Reporting and Learning
System (NRLS), which will allow for: rapid identification of patient
safety threats, swift alerts of the risk to the anaesthetic community
and expert advice on how to resolve the issues. Ultimately this
initiative will advise the specialty on areas requiring further
investigation, through audit and research, and subsequently suggest
additions to our training programme or changes in practice for
improved patient care and risk reduction.
What do you consider are the main risks to patients
within your specialty area?
6. The initial results of the pilot of anaesthesia-related
incidents from the NPSA's reporting system reveal the following
from 149 reports:
Drug issues: 21 incidents, including: non-adherence
to prescribed insulin regimen; adverse reaction to Gelofusin;
anaphylaxis to muscle relaxant, antibiotics and induction agent;
overdose of antibiotics; wrong inhalational anaesthetic agent
selected; inadequate reversal of muscle relaxant; epidural block
inadequate and wrong drug selected when distracted.
Equipment issues: 34 incidents, including: failure
of capnograph; fibre-optic intubation equipment not available;
wrong intravascular equipment selected; failure of intravenous
(IV) infusion pump; displacement of endotracheal tube during transfer;
disconnection of ventilation tubing during procedure; inadequate
IV equipment for obese patient and anaesthetic machine not checked
by senior anaesthetist.
Anaesthetic/other clinical problems: 56 incidents,
including: unexpected failed intubations; laryngospasm; aspiration/regurgitation
of gastric contents; inadequate preoperative assessment; malignant
hyperpyrexia and tooth displacement.
Other: 38 incidents, including: insufficient
portering staff; non-availability of critical care beds; theatre
too hot to work in; communication failures on patient arrival;
problems with identifying the site of surgery; delay in blood
transfusion; transfer equipment not charged and the non-availability
of case notes.
7. Anaesthesia, as a medical specialty,
the largest in the NHS, requires extremely high levels of skill
and vigilance in all areas and frequently demands that immediate
decisions are made to prevent catastrophic injury or loss of life.
Anaesthetic drugs are some of the most potent in use in the hospital
environment and their ability to be employed to save lives is
matched by their immediate life-threatening properties if used
inappropriately. Similarly, the correct use of, often complex,
anaesthesia-related equipment requires appropriate training and
maintenance of skills. Therefore, the main risk to patients would
be the use or attempted use of such drugs and equipment by individuals
who are insufficiently trained or who have not maintained their
skills. Subsequent concerns in this area centre upon incorrect
drug administration in the following areas: wrong patient; wrong
drug; wrong dose; wrong time; wrong route of injection (eg spinal
preparation administered into a vein).
8. As drugs have developed, so too has the
equipment used to support anaesthetists in theatre and intensive
care environments. Patients may be placed at direct risk where
equipment is old or poorly maintained and fails to provide adequate
indication of patient deterioration to the anaesthetist. The provision
of new equipment also presents significant risks linked to the
introduction of technologically advanced life supporting machinery,
especially where this occurs without appropriate training for
9. Several other areas highlighted in the
pilot are low frequency but potentially high impact situations
and more research will be required to evaluate their true risk
potential. The remainder, principally resource issues, involve
aspects outside of the specialty and will require wider consultation
with other stakeholders outside of anaesthesia.
What are the principal causes of harm to patients
within your specialty?
10. Anaesthetists recognise that a direct
and immediate risk to their patients is presented by the medications
used in anaesthetic care, specifically those that lead to loss
of a patent airway and/or depress breathing eg muscle relaxants
and opioids as well as others which acutely depress brain or circulatory
function. Several published surveys have suggested that most practising
anaesthetists have experienced at least one drug error.
It is this area more than most which has promoted studies to identify
specific areas of drug risk and suggested risk reduction initiatives.
11. It was widely known that a key risk
and potential cause of harm was the possibility of confusion among
the numerous (often more than six) drug syringes present around
the patient during an operation or in other clinical areas. In
2003 the College, with key medical partners, issued a proposed
standardisation chart for colour-coding the labels of all such
syringes. This was widely accepted and after a minor revision
and re-issue in 2004 it became the standard reference material
for all anaesthetic, and many other, drugs used in the UK.
12. Medical equipment has changed in response
to technological advances eg in computer processing capabilities.
Nowhere in the hospital is this more obvious than in the operating
theatre and intensive care unit. Risks associated with old or
poorly serviced equipment may be better recognised and checks
are in place to deal with this; however, new equipment carries
the additional risk of unfamiliarity. The Association of Anaesthetists
of Great Britain and Ireland (AAGBI) produce a checklist, endorsed
by the College, to identify equipment that may present a risk
to the patient. Checking Anaesthetic Equipment 3 (2004) directs:-
Before using any anaesthetic equipment, ventilator,
breathing system or monitor, it is essential to be fully familiar
with it. Many of the new anaesthetic "workstations"
are complex pieces of machinery. It is essential that anaesthetists
have a full and formal induction on any machines they may use.
A short "run-through" prior to an operating session
is not acceptable.
This is used as the fundamental principle when
choosing new anaesthetic equipment. Work with the AAGBI and others
has highlighted safety training issues and that manufacturers
should have a clear duty to provide adequate and continuing training
in the use of their equipment. The selection of new equipment
should ideally involve the whole Department of Anaesthesia, especially
College Tutors, to ensure appropriate training and safe use.
13. Anaesthesia has developed to become
a very safe specialty but adverse and "near miss" incidents
still occur, and these often involve human factors. Anaesthesia
needs to continue its proud record and work towards improved systems
for patient safety by learning from these adverse events. Anaesthesia
training includes an element of "human factors" or "non-technical
skills" to ensure communication with colleagues is recognised
as an important part of anaesthesia practice. In addition, the
College recognises that risks are created by differences in practise
between the many healthcare professionals that may be present
in the theatre or critical care environment. We are a partner
in a "safety alliance" group, formed by the Royal College
of Surgeons of England, where shared learning for safety is the
theme. This alliance includes nursing and ODP colleagues together
with patient representatives and, importantly, contributors from
other risk professions, such as the aviation industry.
What actions should be taken to reduce harm within
14. This College recognises that in order
to reduce harm the sources, or potential sources, of that harm
must be clearly identified. For several years the RCoA has been
interested in developing a national critical incident reporting
system which would allow for shared learning in anaesthesia and
would be based on standardised critical incident report forms.
The College issued guidance and templates for critical incident
reporting in the anaesthesia environment in 2001; these were designed
for local hospital use and widely taken up. These templates continue
to be used for local reporting, but the opportunity was not available
for this to develop into a national repository for anaesthesia
15. In close partnership with the College,
the NPSA formed an Expert Consultative Group to review anaesthesia
risks. They decided that before making firm recommendations on
how to prevent drug errors during anaesthesia, workplace evaluations
will take place and two different methods were proposed to reduce
a. Second-person double checking:
Second-person double checking is an established
method of minimising errors during blood transfusion. It is this
method in particular that may contribute to the avoidance of the
various "wrongs" associated with drug administration
as highlighted above at item 6. An editorial in Anaesthesia supported
the use of double-checking during anaesthetic practice.
The objectives of the work-place evaluations will be:
i. Will this practice be accepted by anaesthetists
and other allied professionals?
ii. What may be the practical and/or cultural
challenges or barriers in its introduction?
b. Electronic double-checking using bar-code
In New Zealand, Merry has developed a new drug
administration and documentation system designed to reduce drug
administration errors during anaesthesia. The system utilises
bar-coding to provide double-checking prior to drug administration.
Its effectiveness has been demonstrated outside the UK.
Work-place evaluation will be used to determine if this system
could be introduced into NHS hospitals and, if so, what may be
the practical and/or cultural challenges or barriers to introducing
16. If the piloting of this error-reduction
initiative proves successful then patient safety will be enhanced
allowing the RCoA and the AAGBI to
provide rapid feedback on previously unknown incidents
providing reminders on severe incidents
that occur rarely but are known
permitting peer comparison through
learning from near misses
engaging anaesthetists in reporting
patient safety incidents
17. The Expert Consultative Group evaluated
several possible topics for immediate consideration and decided
that creation of a specialty-based reporting system would improve
critical incident reporting by providing a single point of entry
for data submission.
18. Specialty Specific Incident Reporting
in Anaesthesia will form part of a two year "Anaesthesia:
Improvement through Partnership" project which is being led
by the Royal College of Anaesthetists with the support of the
National Patient Safety Agency and the Association of Anaesthetists
of Great Britain and Ireland. This reporting system will integrate
the information required by anaesthetists with the National Reporting
and Learning System, and will also allow the RCoA and AAGBI to
access data so that they can have a role in analysis and subsequent
19. For the purpose of this project a specialty
specific e-form has been developed for the reporting of incidents,
this is web based and can be accessed directly from the internet.
It is anticipated that this will improve patient safety in anaesthesia
Allowing the NPSA, RCoA and AAGBI
to provide rapid feedback through clinical networks on previously
unknown "high priority" incidents
Allowing for the provision of national
learning from actual incidents and "near misses"
Providing a constant reminder on
severe incidents that occur rarely but are known
Allowing for peer comparison through
provision of benchmarking data
Allowing for dissemination of information
on risk-prone situations, which can be shared through networks
and proactively managed locally
Further engaging the anaesthetic
profession in reporting patient safety incidents
20. The specialty specific reporting system
is currently being piloted in thirteen Trusts. The pilot is running
from MaySeptember 2008 and will then be fully evaluated
before further roll out. In the long term, it is hoped this system
will allow for a single portal of entry for anaesthesia-related
incidents in the UK, which in time will allow a national picture
of anaesthesia-related incidents to be assembled. The system will
also allow in depth trend analysis and a rapid response to adverse
incidents if necessary.
21. A Safe Anaesthesia Liaison Group is
in the process of being established which will comprise core membership
from the RCoA, NPSA and AAGBI. This group will be administered
by the RCoA and will produce and disseminate regular reports on
safety issues in anaesthesia based on incident data and also make
recommendations for future safety improvement initiatives and
the need for further research if applicable.
What would you like to see done to increase the
safety of patients in the NHS as a whole?
22. This specialty reporting initiative
now provides the NPSA with the opportunity to meet the requirements
of the RCoA and also to develop a template for specialty-based
reporting which may be transferable to other specialties in the
NHS; a key example would be obstetrics and gynaecology. The system
development has included the following key success-targeted principles:
a user friendly approach
a specialty-specific focus
sensitivity to the confidentiality
of the reporter
it is complementary to the local
reporting systems of the hospitals
it is responsiveie each reported
incident should generate an appropriate response intended to improve
23. The joint working between three major
national bodiesthe NPSA, RCoA and AAGBI in this example
may be easily replicated for other specialties and the approach
has been developed to be generic enough to be adapted by others.
Principally, we have encouraged the involvement of independent
experts, patient representatives and national bodies representing
ODPs and nurses and this has encouraged buy-in and expanded feedback.
24. Wide consultation and risk assessments
at local and hospital level, with the involvement of local risk
managers, encouraged operational input at the most appropriate
level and provided an excellent route for regular feedback to
the hospitals and practitioners. This is not a system which is
constrained to anaesthesia and could be easily adapted for the
development of similar risk reduction systems throughout the NHS.
25. Finally, by informing future audits,
areas for guidance, training, professional standards and research,
this partnership approach by involved and informed organisations,
together with representative patients, allows for the development
of a national culture of patient safety in a comprehensive, co-ordinated
and consultative manner.
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