Safety InAnaesthesia andLearning fromIncidents

Welcome to the latest edition of the King’s SALI newsletter for all sites at King’s: Denmark Hill, Orpington & Princess Royal. This installment comes to you from a new editorial team of Andy Ham and Andy McKechnie. I am sure you will notice NO significant improvements but we aim to focus on safety incidents and issues important to you and your practice in the following months so feel free to contact us with suggestions. Please be assured that only incidents that have a wider learning point will be highlighted and individuals will not be identified or scrutinised in any form. If you have any comments, queries or suggestions please contact lorraine.schwanberg@nhs.net

SALI Newsletter – 5th Edition April 2015

Anaesthetic Adverse Incidents Reported for the Anaesthetic Department to Investigate

Summary of Incidents

Reported Incidents of “Drug Errors”

Extract from the latest SAFE Anaesthetic Liaison Group

Analysis of reports of medication incidents identifies wrong dose, omitted or delayed medicines and wrong medicine as being the most frequent errors made. The acute care sector is the highest reporter of medication errors, and the most serious incidents are caused by errors of administration rather than prescribing. Incidents involving injectables accounted for 62% of all reported incidents leading to death or severe harm in an analysis of reports to the NRLS in 2007 – 2009.(1)

NHS England Patient Safety Division provides useful information and guidance on medication safety, as well as links to important signals and alerts.(2)

1) NRLS - NPSA - Safety in Doses: improving the use of medicines in the NHS, 2009. http://www.nrls.npsa.nhs.uk/resources/?entryid45=61625

2) NRLS - NPSA – Medication Safety, 2014. http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/medication-safety/

TAVI procedure in Cath-Lab… end of procedure plan to reverse heparin with Protamine… 5mls of Protamine and 4mls of neat Noradrenaline drawn up in error… 5mls of mixture administered to patient… blood pressure un-recordable for 3 minutes… line aspirated, Propofol given and vapour increased… Patient had no cardiovascular or neurological sequela. Drug storage in cath labs was reviewed and anaesthetist reflected on incident.

Emergency Caesarean section for second twin who was breach and had become profoundly bradycardic during ECV… Anaesthetist began pre-oxygenation and asked ODP to draw up drugs for RSI… At time of Suxamethonium administration patient noted to still be awake… Anaesthetist asked to check drug vial which was then noted to be Augmentin rather than Thiopentone… Rapid Induction Tray was stocked with incorrect drug... Patient reassured and Propofol administered… Intubation of patient and delivery of baby with no further complication… Patient reported explicit recall up to the point just before laryngoscopy… Patient followed up by two Anaesthetic Consultants who referred patient for psychotherapy support. Staff reflected on incident and provided helpful suggestions to prevent reoccurrence.

Patient transferred from Neuro Theatres to ICU post Craniotomy for Subdural Haematoma... Noted to have heart rate of 160 with very labile blood pressure (systolic ranging from 180 to 70), significant Base Excess -7.5, lactate 6.2… Patient handed over as being on Noradrenaline which had been “drawn up in another theatre”… When checked was found to actually be on Adrenaline, which was being administered via a grey cannula in femoral vein… Central venous access achieved and patient changed to Noradrenaline – Blood gas improved

Armoured ET TubesThere have been 2 reports of patients being admitted to ITU from theatres with armoured/reinforced ET tubes in situ. The first was a case from main theatres that demonstrated evidence of kinking from biting on the tube. The second was from neuro theatre and on decreasing sedation the patient bit down, kinked the tube and suffered transient desaturation, distress, failed extubation and a period of further ventilation.The policy states that if an armoured tube is needed in theatre it should be changed to a non-reinforced version prior to ITU admission to allow weaning. If this is not possible or advisable for any reason (e.g. difficult airway) this should be fully explained to the receiving unit…

NG tubes and equipmentA large bore calibrating NG tube was inserted in a patient undergoing a laparoscopic procedure. The anaesthetist was unfamiliar with the device so sought advice from both the ODP and surgical team before proceeding to inject blue dye into the presumed gastric port. It became apparent that in fact 150ml dye had been wrongly injected into the balloon port.

It should be remembered that there are a number of different types of NG tubes in use throughout the trust… This incident also reaffirms the fact that staff should not use equipment they are unfamiliar with.

Cardioversion and CommunicationA patient was admitted to ED following collapse and was noted to have ECG changes and haemodynamic parameters requiring need for urgent cardioversion. ED team spent 25 minutes trying to get first the ITU SpR and then anaesthetic SpR to take responsibility for the patient without success. The patient was subsequently cardioverted in ED by the ED team without airway expertise being present.

The details of the discussions that occurred are unclear but clearly communication between teams was not ideal. It should be remembered that cardioversions cannot always be performed in theatre in an emergency and that patient safety must come first.

Incidents Reported

Day Care AdmissionA child was noted to be slow to wake post dental procedure in day care. The patient only woke up to vomit and as such was thought by nursing staff to not have a safe airway. The anaesthetist had left the building and no other consultants were present. On investigation one anaesthetist had to go home sick that day and it was not clear who the starred anaesthetist was. The on call anaesthetist had to become involved and the child was admitted to paediatric ward overnight.

It is the responsibility of the individual anaesthetist to ensure that recovery are happy with their patients prior to leaving for the day… It is also suggested that the “starred” anaesthetist ensures there are no problems before leaving.

Handover and CommunicationEffective handover is key to continuity of care and patient safety. Unfortunately failures in communication and handover continue to occur frequently. Many reported incidents relate to anaesthetic handover to recovery for which the new recovery handover protocol may guide practice. In addition we must remember that when returning patients to ITU post operatively we should fully inform the receiving team of all clinical details to allow care of the patient to continue. An ITU handover protocol may be developed for this situation.

Peribulbar BlockA peribulbar eye block was performed by a trainee fully supervised by a consultant. The patient had 7mls injected into the lateral infraorbital site and became mildly agitated but this resolved. A further 3mls was then injected into the medial canthus. The patient showed evidence of a 7th cranial nerve palsy with inability to close left eye lid, drooping of left corner of mouth and numbness to the left side of face. The patient was closely monitored and 3 hours post injection there was no evidence of deficit. The patient was made fully aware of the complication and was followed up in eye clinic.Cranial nerve palsy is a rare BUT recognised complication of peribulbar anaesthesia… This case demonstrates a thorough and professional approach to a complication and is included as a lesson in effective management.

Epidural IssuesThere was a case of a patient with a post-operative epidural infusion being sent to a non-accredited epidural ward… This was discovered by the pain team during a ward round.It is worth remembering that not all wards will take patients with epidurals– details of suitable wards can always be clarified with the nurses holding the pain bleep.

In a related incident, a paravertebral infusion using 0.25% bupivacaine was set up and run via a syringe driver. The policy states that for safety reasons an epidural pump should be used in this situation.

PICU AirwayAn incident was reported involving anaesthetic airway support on PICU that highlights a number of issues. Anaesthetic SpR was called to assist with the airway in a 2 month old infant on PICU as the 2 PICU registrars had been unable to intubate the child despite 3 attempts. It is stated that 699 was unhappy to attend unless the PICU consultant was also present on the basis that it was a known difficult intubation. On arrival 699 noted that the baby was being adequately ventilated via facemask, that PICU had failed to intubate on 3 occasions and that PICU consultant was coming in to assist. The anaesthetic registrar decided to leave PICU as the baby appeared to be “stable”. The patient was hand ventilated via facemask by the PICU team for a further 45 minutes until the PICU consultant arrived and intubated… The patient required a chest drain for a large pneumothorax… PICU were unhappy with the anaesthetic management.Policy states that the 699 bleep holder is the anaesthetist “on call” to assist paediatric patients at DH… In addition 699 has the support of a consultant paediatric anaesthetist 24hrs a day… In situations where a paediatric patient has a presumed or known difficult airway, it would seem sensible that the most senior anaesthetist in the hospital (699 after hours) remains with the patient… In addition, it should be remembered that good communication and cooperative teamwork is key to patient safety.

Extravasation of RocuroniumCannula sited in Antecubital Fossa. Extravasation of 300ml of Hartmans and 30mg Rocuronium. Arm elevated in sling… Prolonged time in recovery to ensure no delayed neuromuscular blockade… FU on ward by imobile.

Repeat dosing of medicationsPatient received 1g of IV Paracetamol on the ward then 2.5 hours later received second dose in theatre. Patient weighed 46kg.

Take care to check drug charts – both paper and electronic – before administering drugs which may already have been given. The commonest errors are with antibiotics and Paracetamol.

PCA and NCA IssuesPCA set up with Fentanyl… Bolus given, during which it was noted that a large volume of the drug was being administered… 700mcg had been given by time this was noticed… Pump checked and it was found to have been programmed as bolus dose of 1mg… Patient required naloxone infusion and CPAP respiratory support… PCA removed and epidural sited… Details of case handed over to ITU team.This case highlights the importance of vigilance when programming PCA pumps particularly when using a non-standard programme.

Patient returned from theatre with NCA pump in bed... NCA not programmed or attached to patient... No anti-syphon valve in situ… Prescription not valid… Patient woke up in pain.It is the Anaesthetist’s responsibility to ensure that NCAs are appropriately prescribed and set up before handing a patient over to recovery.

Patient in area of trust where PCAs are delivered intravenously… No dedicated line for PCA to run was in situ.

TED StockingsPatient received from Cardiac theatres without TED stockings in situ. Anaesthetists should be aware of the guidelines regarding prevention of venous thromboembolism and this should be specifically addressed at the time of the WHO sign-in.

MRI SafetyBoth Anaesthetist and ODA present on MRI list were agency. Unfamiliar with environment, equipment and MRI safety procedures. Anaesthetist suggested taking Oxygen cylinder into scan room. Following this incident a training programme has been established for ODAs with only those accredited being allowed to do lists in MRI. A refresher on MRI safety for anaesthetist is in the process of being organised for the next Audit meeting.

Line Flushing IssuesThere have been two reported incidents with relation to the flushing of lines… In the first case a 26kg paediatric patient was undergoing an ORIF elbow, intra op management was uneventful… The cannula was flushed with normal saline at the end of the case (in theatre) but some residual blood was noted in the giving set so a second flush was used… It became apparent to the anaesthetist that the syringe containing the unused morphine was empty and that the 7.5mg of morphine remaining had been used to flush the line… A tourniquet was applied and the cannula was aspirated and removed... The patient was monitored closely for signs of opiate toxicity and was extubated uneventfully after 10 minutes… The patient was kept in recovery for 1 hour and showed no adverse sign. In the second case, a paediatric patient was taken to recovery post GA… The patient was awake, alert and saturating at 100%... The femoral Line was flushed in recovery… The infant immediately became drowsy and apnoeic with saturations of 47% and heart rate of 70bpm… Immediate action was taken and patient recovered over the course of 1 minute with no further issues.

The first case here highlights the need for vigilance when flushing any lines to ensure you are flushing with only saline. The second case serves to highlight the value of ensuring lines are flushed in theatre before moving to recovery where equipment and expertise are more readily available to deal with any ensuing respiratory compromise from residual anaesthetic drugs in lines.

Needle Stick InjuriesThere have been two reports of needle stick injuries involving theatre staff during this quarter. We would like to remind people of the hospital policy for the management of these injuries. Immediate first aid suggests encouraging the wound to bleed and washing under tap with soap or chlorhexidine. In hours (0900-1630) the staff member should contact Occupational Health which has a drop in service or out of hours should attend ED immediately (within 1 hour). You should take the details of the patient with you so you can be risk assessed regarding the appropriateness for Post Exposure Prophylaxis and other follow up. An incident form should also be completed. Restraint in ChildrenAnxious child booked for MRI under GA… Mother wanted to restrain child so GA could be administered but Step-Father not happy with use of restraint… Anaesthetist unhappy to restrain child… MRI cancelled and rebooked to be performed at later date with premedication.The anaesthetic department is seeking further advice on the use of restraints for paediatrics. The Trust has a Restraints Policy which all staff should be familiar with. The incident has been flagged to Child Health and the authors of the Policy- we will update you of the outcome…

Editors: Dr Andrew Ham, Dr Andrew McKechnie, and Lorraine Schwanberg. Many thanks to Dr John Sedgwick.

Check out www.kingsairway.net for airway education and safety guidelines.