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

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    Kamel Hady
    This document summarizes safety updates from various organizations in 2010-2011. It discusses the expanded list of "never events" from the Department of Health, incident reports analyzed by the Safe Anaesthesia Liaison Group, alerts on issues like shared ampoules from the National Patient Safety Agency, device and drug safety from the MHRA, AAGBI statements on capnography and sedation, and ways the safety committee contacts anesthesiologists with updates.

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

    Uploaded by

    Kamel Hady
    49 views28 pages
    This document summarizes safety updates from various organizations in 2010-2011. It discusses the expanded list of "never events" from the Department of Health, incident reports analyzed by the Safe Anaesthesia Liaison Group, alerts on issues like shared ampoules from the National Patient Safety Agency, device and drug safety from the MHRA, AAGBI statements on capnography and sedation, and ways the safety committee contacts anesthesiologists with updates.

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    15 00 Safety Committee Linkman

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    This document summarizes safety updates from various organizations in 2010-2011. It discusses the expanded list of "never events" from the Department of Health, incident reports analyzed by the Safe Anaesthesia Liaison Group, alerts on issues like shared ampoules from the National Patient Safety Agency, device and drug safety from the MHRA, AAGBI statements on capnography and sedation, and ways the safety committee contacts anesthesiologists with updates.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    49 views28 pages

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

    Uploaded by

    Kamel Hady
    This document summarizes safety updates from various organizations in 2010-2011. It discusses the expanded list of "never events" from the Department of Health, incident reports analyzed by the Safe Anaesthesia Liaison Group, alerts on issues like shared ampoules from the National Patient Safety Agency, device and drug safety from the MHRA, AAGBI statements on capnography and sedation, and ways the safety committee contacts anesthesiologists with updates.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 28

    Safety Committee Update

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

    2010/11: an overview
    DH

    NPSA
    MHRA Safe Anaesthesia Liaison Group
    Patient Safety Updates

    AAGBI Statements

    DH Never events

    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-nave patient

    NPSA
    Review of DH Arms 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 (2003-2010)


    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, CO2 absorber Power supply AMBU bag

    Medication
    Paracetamol TIVA

    Treatment/procedure
    Residual drugs Motor block assd 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!


    secretariat@aagbi.org

    Summary
    Never events framework Incident reporting
    Treatment/procedures Medical devices Medication

    Capnography statement

    Sedation
    Neuraxial connector risk assessment

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