Making Anaesthesia Safer

Patient safety is core to all aspects of the College’s training, education and standards for anaesthesia, critical care and pain medicine.

What is patient safety and what is an untoward incident?
When a patient receives health care, the highest possible standards are intended and expected. These standards cover the medication prescribed, the equipment used, the environment in which that care takes place and the actions of the people responsible for that care.

Occasionally an unexpected event may occur or the patient’s response to the treatment may not be as anticipated. When these things happen, this event is described as a patient safety incident or an untoward incident. In serious cases, this may describe a situation where the patient has been harmed. Any harm sustained by a patient not caused by their existing health problems is considered a patient safety incident. Research shows the majority of safety incidents are caused by failures in systems rather than the fault of an individual healthcare professional.

Reporting and learning
In order that patient safety incidents are kept to a minimum, and to work towards eliminating them completely, the Royal College of Anaesthetists (RCoA) encourages clinicians to report any patient safety incidents that occur during their work. By doing this, analysis of risks and accidents that may have harmed a patient previously can be shared. Clinicians can then learn to take the relevant precautions to prevent similar incidents happening again. In partnership with the NHS Commissioning Board (NHSCB) and the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the College is taking the lead in reporting and learning from patient safety incidents.

An increase in the number of reported of incidents can lead to a greater level of concern amongst the public. But, increased reporting usually indicates an increased attention to safety issues and a wish to share what has been learned. Reporting helps to ensure similar incidents are less likely to happen again. In fact, it is unlikely that increased reporting denotes a rise in the number of untoward incidents.

The Safe Anaesthesia Liaison Group
The Safe Anaesthesia Liaison Group (SALG) includes members of the RCoA, AAGBI and NHSCB. A representative from the RCoA Patient Liaison Group also sits on the Group. There are also a wider number of advisory members drawn from anaesthetic subspecialties and other organisations with a patient safety focus. This wide range of expertise is tasked with reviewing the reports and turning them into tools for learning or to recommend changes in current practice. The terms of reference for the SALG can be viewed here. 

Tools for Learning
An example of the learning outcomes of reporting is the SALG Safety Notification – Guaranteeing Drug Delivery in Total Intravenous Anaesthesia. A number of reports were made by healthcare professionals concerning the risk of inadequate amounts of anaesthetic drugs being administered. This risk resulted from the use of specific equipment for this procedure which was shown to have unexpected limitations. In response to these reports, SALG produced a Safety Notification which was disseminated widely across healthcare networks, websites and publications to inform clinicians of the risk and to advise on specific safety precautions. The notice can be viewed here.

Should I be worried?
Every healthcare procedure carries an element of risk and for the majority of patients this risk is very low and an untoward incident is highly unlikely to happen. Even so, we are not complacent and there is always room for improvement. Media reports of a rise in the reporting of incidents should not be seen as a reason to be more concerned about undergoing a healthcare procedure, but rather a sign that all areas of healthcare are coming under the microscope more than ever before, to see what has gone wrong in the past and to ensure it does not happen again in the future.