Patient Safety Update April 2024-October 2024

The SALG Patient Safety Updates contain important learning from incidents reported to the National Reporting and Learning System (NRLS). The RCoA and the Association aim to bring these Safety Updates to the attention of as many anaesthetists and their teams as possible. The updates are published quarterly and contain data from an earlier time period.

In collaboration with the Association of Anaesthetists and the Royal College of Anaesthetists, SALG are offering a unique programme of formal training through Harvard Medical School that aims to develop international expertise in perioperative quality and safety. The successful candidates will be provided with:

• A fully funded place in a Master of Healthcare Quality and Safety course from Harvard University, while also engaged in clinical practice at a suitable level at the Beth Israel Deaconess Medical Centre (BIDMC), a major Harvard Medical School teaching hospital in Boston
• Co-mentorship during the programme under the leadership of the BIDMC department chair, Professor D Talmor, from:
  • Prof Satya-Krishna Ramachandran at Harvard/BIDMC
  • The co-chairs of SALG
  • Professor JJ Pandit (University of Oxford)
• Scholars will identify project(s) in the UK that they will develop and lead on, after their return to the UK

Further information about this opportunity, and details of how to apply can be found on the SALG website.

This year’s SALG Patient Safety Conference, which will be held online on Wednesday 12th November, will focus on the topics of Local Anaesthesia Systemic Toxicity and Rapid Sequence Induction, along with safety updates from our partners. We do hope that you’ll join us for what promises to be an interesting and useful day.

SALG has continued to concentrate on improving medication safety in 2025, with a particular focus on improving availability of pre-filled syringes of anaesthetic medications. The group are currently working with stakeholders from a variety of organisations to support this agenda.

SALG would like to draw attention to the recent publications from the Association of Anaesthetists and MHRA regarding perioperative care of patients currently taking GLP-1 agonist medications (e.g. Ozempic, Wegovy etc.)

SALG would like to ensure that anaesthetists are aware that prolonged release opioids are no longer licensed for the treatment of post operative pain. The use of these medications is associated with an increased risk of persistent post-operative opioid use and opioid induced ventilatory impairment.

All Prevention of Future Deaths reports received by the RCoA/Association of Anaesthetists are reviewed by SALG and a joint response produced. The RCoA and the Association were requested to respond to a report from a coroner following the sad death of a patient, Mrs Pamela Marking.

This content has been developed for SALG by the consultant anaesthetist involved in the individual case.

A patient underwent caesarean birth under epidural (‘top-up’) anaesthesia. Shortly after delivery, the patient started to haemorrhage and 1g tranexamic acid (TXA) was requested. While preparing the drug for administration, one of the ampoules of TXA was ...

This incident was originally reported to NHSE. Further details have subsequently been provided by the trust.

Following delivery, five units of oxytocin were administered intravenously (IV), during an emergency Caesarean section. The uterus remained poorly contracted and there was excessive bleeding. In response the obstetrician requested  a further 5 units of IV oxytocin and tranexamic acid in line with guidance for managing post-partum haemorrhage.

The anaesthetist slowly injected the solution from a 5ml ampoule [thought to be TXA] IV. Approximately 2 minutes later the patient became restless, her breathing became shallow, and she became unresponsive. The patient required intubation and ventilation...

Following are reviews of incidents reported to the NHS in England and Wales in the period from 1^st April -31^st October, 2024.

This content has been generated for SALG by the Perioperative Allergy Network

Case 1

A patient underwent general anaesthesia for urgent laparoscopic cholecystectomy. Following a modified rapid sequence induction with propofol, remifentanil and rocuronium, it was noted the patient’s heart rate had increased from ~100 to ~150bpm, with a fall in blood pressure from 127/63 to 65/33. Mild erythema over the upper chest and face was noted. A clinical emergency was declared resulting in assistance from several consultant anaesthetists. IV adrenaline (1x 100mcg IV) was given with resolution of the hypotension and tachycardia. Ephedrine was subsequently given...

This content has been generated for SALG by the Difficult Airway Society

A young adult was admitted for elective foramen magnum decompression. The patient had a rare congenital syndrome associated with a high likelihood of a difficult airway. Awake fibreoptic intubation with maxillofacial team support was planned...

This content has been generated for SALG by the Association of Paediatric Anaesthetists of Great Britain and Ireland

A previously well [paediatric] patient was referred to the retrieval team by the emergency department of a hospital without specialist paediatric services  in the early hours of the morning...

This content has been generated for SALG by the Association for Cardiothoracic Anaesthesia and Critical Care

Dislodgement of the drainage cannula of a left ventricular assist device (LVAD) resulted in a major haemorrhage. The flow through the LVAD suddenly dropped then spontaneously resolved...

Case 1

A  patient who had become hypotensive with ECG changes during attempted spinal insertion was transferred to a nearby hospital for monitoring. Cardiologists at this hospital  considered the patient required primary percutaneous coronary intervention (PPCI) which was not available  so the patient was transferred for a second time...  

A patient requested an epidural during labour of a stillbirth. While siting the epidural, the anaesthetist was called away to an emergency c-section. An hour later, the anaesthetist was called to a second obstetric emergency c-section. The Senior midwife bleeped two other anaesthetists who were  unable to attend...

Delay to a patient’s surgery, due to lack of theatre availability, caused significant deterioration in their mental health. The patient was known to have mental health issues, and a plan had been made for pre-medication but due to the delay this did not happen...

A patient suffered a 3000ml haemorrhage during elective gynaecology surgery undertaken during a weekend waiting list initiative. The list was overbooked. None of the patients attended pre-assessment...

A patient in their 40s with a stroke underwent thrombolysis in the emergency department and  was referred to the local stroke unit. The transport requested by the ED consultant was unavailable and a plan was made to undertake transfer with an clinician from the hospital and the local ambulance service...

On arrival in the recovery unit in the late evening a patient was found to be unresponsive with shallow breathing and unrecordable SpO2. They rapidly went into cardiac arrest, requiring advanced life support...

Case 1

A Patient with COPD, SpO2 on air of 93%, underwent transsphenoidal surgery for acromegaly after full preoperative work-up in the high-risk clinic. The surgery was uncomplicated... 

A patient developed a haemothorax due to left innominate vein injury. This occurred during insertion of a veno-venous (VV) bypass line in the right internal jugular vein during adult liver transplantation surgery...

An attempt to insert a supra-scapular block by an anaesthetist was unsuccessful, and surgery was conducted under GA instead. Postoperatively the patient developed shortness of breath, required supplemental oxygen then collapsed...

Case 1

A patient was admitted to the emergency department with complete airway obstruction due to possible regurgitation and aspiration of solid material. On arrival of the anaesthetic team, the SpO2 <30 with a good trace, with pO2 4.45.

A patient developed signs of sepsis in the post anaesthesia care unit following emergency surgery. Hypotension was resistant to fluid challenges. Post operative instructions were to continue antibiotics; however, the electronic prescribing and medicine administration record contained no details of previous doses given.

Case 1

A central line was sited by an FY2 doctor supervised by a more senior resident doctor. The hospital protocol was followed, and the guidewire position was confirmed with ultrasound. A post procedure chest x-ray was reviewed by the more senior resident doctor, who confirmed positioning.