Select Committee on Health Written Evidence

Memorandum by the Royal College of Anaesthetists (PS 70)


  1.  In constructing this response we have noted the Health Committee brief and, as requested, provided short and individual responses to questions—identifying 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 College—anaesthesia, critical care and pain management.


  2.  The Royal College of Anaesthetists was granted a Charter[370] 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 safety.

  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 the user.

  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.[371] 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 your specialty?

  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 safety information.

  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 errors:

    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.[372] 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 methodology:

    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.[373] 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 this practice?

  16.  If the piloting of this error-reduction initiative proves successful then patient safety will be enhanced by:

    —  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 benchmarking

    —  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 dissemination.

  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 through:

    —  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 May—September 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 responsive—ie each reported incident should generate an appropriate response intended to improve patient safety.

  23.  The joint working between three major national bodies—the 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.

September 2008

370   The Royal College of Anaesthetists, Charter and Ordinances, RCoA (1992). Back

371   Merry AF et al. Anaesthetists, errors in drug administration and the law. N Z Med J 1995; 108:185-7. Back

372   Bell D. Recurrent wrong-route drug error-a professional shame. Anaesthesia 2007; 62:541-4. Back

373   Merry AF, Webster CS, Larssen L, Wells J, Fryben C. Prospective Assessment of a new anaesthetic drug administration system designed to improve safety. Anesthesiology 2006; 106:A138. Back

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Prepared 30 October 2008