Details of a programme aimed at improving the safety of anaesthesia were recently highlighted at a conference held by the College of Operating Department Practitioners (CODP) at Fontwell Park racecourse, in Arundel. The “Improvement Through Partnership” initiative has identified 12 recommendations as part of a two-year project supported by the Royal College of Anaesthetists, CODP, the Association for Perioperative Practice and the Association of Anaesthetists of Great Britain and Ireland.
She added that this is likely to be the “tip of the iceberg” as many incidents go unreported. While 75% of these result in “no harm”, 1% prove fatal and an additional 1% lead to “severe” harm. The problem of retained throat packs continues to be an issue and the results of an investigation into this area will be published in 2009.
She also revealed that a safety package has been developed which includes the development of a specialty specific reporting system for anaesthesia and a pilot study to examine the role of double-checking in improving the safety of administering injectable anaesthetic drugs.
Three priority areas will be:
• The development of a dedicated way for anaesthetic staff to report patient safety incidents.
• Investigating two methods of doublechecking anaesthetic drugs given by injection.
• Evaluating the effectiveness of direct communication through professional networks. A known patient safety issue (retained throat packs) will be used in the evaluation.
An interactive methodology for the two-person check has been developed as part of this study, which includes a system of barcoding technology, as well as colour coding. Joan Russell explained that a voice prompt could be linked to the barcode on the drug, to ensure the correct one is used, and this would be automatically added to the patient’s electronic record. The barcode system forms part of the Anaesthetic Workstation developed by Professor Alan Merry, who is also involved in the WHO “Safer Surgery” initiative.
