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 three month period.

Welcome to the SALG Patient Safety Update (July-September 2023)

The SALG Patient Safety Update turns 13 this year, so we at SALG felt that it might be a good time to review the way that it is produced and make some changes that we hope will serve to improve its effectiveness and reach.

The new development process uses the expertise of topic experts that we have recruited through the relevant specialty societies and other professional bodies, asking them to look at cases that fall within their topic area. By doing this we expect that they will provide both relevant information in relation to the lessons that can be learned and a link to feed this back to their specialist societies to allow for distribution of the issues arising from the data.

There has also been a fundamental change at NHS England in relation to the way that data are collected. The new Patient Safety Incident Response Framework (PSIRF) provides a framework for improving the quality of investigations/reporting to more effectively identify and implement the systems-related changes that need to take place to effectively respond to patient safety issues. We hope that this new framework will provide more focused learning and will allow us to more easily identify relevant and helpful lessons from within the data.

Included in this update, alongside the usual review of incidents, are other items that SALG has considers relevant to patient safety including lessons for NHS Trusts/Boards, identified by various sources, including NHS England, HSSIB and the Coroners Court.

We hope that you find the new format informative and useful. Feedback, as ever, is very welcome so please do feel free to contact SALG using our email address: [email protected] if you have any questions or comments to make.  

Acetone in the anaesthetic room - time for a change

Through its core work to review recorded patient safety events the NHSE National Patient Safety Team identified a risk involving a LASA (Look Alike Sound Alike) error involving acetone and sodium citrate.

HSSIB Reports

SALG would like to highlight the following reports, based on HSSIB investigations, that contain recommendations relevant to anaesthetists and departments of anaesthesia:

Advanced airway management in patients with a known complex disease

NHS workforce and patient safety 

New two-page quick summary of NatSSIPs

CPOC has now launched a two-page quick summary of the National Safety Standards of Invasive Procedures (NatSSIPs). This is an aide memoire for anyone undertaking interventional procedures and the teams that support them.  

Reports from the coroner

There are two coroners' reports that have been included in this edition of the PSU, these relate to:

Death related to CO2 monitor not working

Use of Aintree intubating catheter for supplemental oxygenation

Review of Incidents

Following is a review of incidents that have been identified from those reported to the NHS in England and Wales in the period from 1 July and 30 September 2023.

Neurological Monitoring Associated with spinal epidural anaesthesia

Following vascular surgery under spinal-epidural anaesthetic, there was no return of any sensation or motor function in the lower limbs (Bromage score 3) within 4 hours. The block was not monitored in recovery and although ward staff raised concerns, there was a delay in review and a significant delay in undertaking a MR scan (more than 10 hours). The MR scan confirmed a suspected hematomyelia (haemorrhage occurring within the spinal cord) and the patient suffered permanent neurological sequelae.

Airway incidents

CASE 1: Peri-arrest call to ward. Patient was vomiting and aspirating and was hypoxic on 15L via a non-rebreathing mask. Proceeded to VF Arrest.