SALG has not been involved in the production of these projects, and as such, we cannot formally endorse them. However, the group is keen to support local safety projects and hopes that this page will help share ideas and promote discussion. The projects are not formally peer-reviewed. Safety initiatives can have unintended consequences, and those wishing to implement projects should be alert to this possibility.
Co-PILOT for better teamwork during difficult airway management
A visual aid designed for ODPs and anaesthetic nurses based on the Difficult Airway Society Guidelines can help promote teamwork
The tool helps the assistant to make suggestions and can avert task fixation and loss of sense of time in a crisis
Anaesthesia should always be undertaken with the help of a trained assistant. Operating department practitioner Dave Howarth and consultant anaesthetist Declan Maloney, from Ysbyty Gwynedd, North Wales, designed the Co-PILOT protocol as a tool to make it easier for the anaesthetist and assistant to work together as a team.
The tool is based on the Difficult Airway Society's guidelines for unanticipated difficult airway management. It offers suggestions that the assistant can make to the anaesthetist based on the guidelines, and so helps both empower the assistant to contribute and provides another prompt to maintain situational awareness and reduce task fixation.
The protocol is divided into 2 columns: The first summarising the DAS guidelines and the second suggesting actions the assistant could take. In a simulation exercise, use of the protocol helped ODPs of all grades to make suggestions to anaesthetists. The simulated airway management task was completed more quickly, and a broader range of input from the assistant was noted.
Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Frerk, C et al. British Journal of Anaesthesia, 115 (6): 827–848 (2015) doi:10.1093/bja/aev371 available here.
Learning from Excellence
- Quality and safety processes in healthcare tend to focus on failures of systems or individuals
- But adverse incidents only account for the minority of healthcare interactions, and focusing on these events may miss important learning from episodes of excellent practice
- A formal reporting system for capturing excellence can reward and reinforce good practice without risking the development of a real or perceived negative culture of blame or retribution
Prompted by his own experiences of care, consultant paediatric intensivist Adrian Plunkett wanted to develop a way to capture and learn from exemplary practice.
He and colleagues at Birmingham Children's Hospital took their our existing incident reporting system and created a new form – an online, simplified incident reporting form – to report excellence.
They don't define excellence themselves, but leave it to the reporters to decide. Individuals who have been reported receive a formal citation from the Trust Governance department in the exact words in which the report was written.
But as well as feeding back to the individuals concerned, the team also study these excellence reports in parallel to the process by which existing incident reports are analysed. Just like incident reports, some excellence reports fall into themes, while others have high learning value and can be investigated in greater depth to unpick the learning points.
The team now receive between 60-80 reports per month, and the rates are steadily rising. They have started using excellence reports as a quality improvement tool, and have already demonstrated some tangible improvements, such as improved prescribing practice.
They report that their initiative demonstrates how excellence reporting can be used to capture information about how practice at the “sharp end” of clinical work manages to avoid errors and preventable harm – an essential feature of any governance system that wants to move beyond retrospective adverse event analysis to the more proactive “Safety 2” approach.
Their initiative is now spreading outside their department, and several other centres are starting similar initiatives.
Learning from excellence in healthcare: a new approach to incident reporting ADC 2016 [epub ahead of print]
A New View of Safety: Safety 2 BJA 2015;115:645-7
Emergency signs for perioperative areas
- Responding quickly to an emergency requires familiarity with the perioperative environment, which is a challenge given changes in equipment, high trainee turnover and frequent use of temporary staff.
- Effective safety signs act as cognitive aids in stressful situations.
- Inspired by the success of the nationally implemented Difficult Airway Trolley sign, a team from the Royal London Hospital have begun designing universal standardised and agreed signage for emergency clinical drugs and equipment that could be used throughout the NHS.
Guidelines published by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) state that 'equipment/drugs for rarely encountered emergencies must be available' and that the 'location must be clearly signed'.
To be useful, emergency signs depend on quick recognition and comprehension, without additional explanatory text. They must also be reliable and consistent over time and across different locations.
The International Organisation for Standardisation has produced standards for emergency signage. The DAS Difficult Airway Trolley sign was developed by anaesthetist Mark Barley of Nottingham and East Midlands School of Anaesthesia to meet these standards, but there are no other signs for perioperative emergencies that have been developed using the ISO approved standards. Queenie Lo, Trudie Phillips and colleagues from the Royal London Hospital set out to develop universal emergency signage using ISO approved standards as a resource for any perioperative team.
To date, they have developed a bank of 13 emergency signs, each with six variants (major trauma trolley, resuscitation trolley, thoracotomy trolley, rapid infuser, anaesthetic fibreoptic scope, malignant hyperthermia box, sugammadex, local anaesthetic toxicity, paediatric anaesthetic trolley, tracheostomy set, one lung ventilation, anaesthetic trolley, emergency alarm), all in accordance with ISO regulations.
Their project has won the approval of both the Safe Anaesthesia Liaison Group at the Royal College of Anaesthetists and the Association for Perioperative Practice, and was awarded third place in the patient safety category at the AAGBI Congress 2015.
They plan to undergo further national testing before launching a nationally recognised set of emergency signs for perioperative areas. Many of these signs are transferable and will also be useful for other areas of the hospital such as emergency departments and labour wards.
The signs depicted are still in development and are © 2016 Clear Sign Medical Ltd. Copyright is reserved (No publishing or reproduction without permission).
Anaesthesia Special Issue: Abstracts of the AAGBI Annual Congress, 23–25 September 2015, Edinburgh, UK. (2015); 70:11-91 (abstract 54).
Examples of emergency signs
TALK: a structured debriefing tool
- Debriefing enhances patient safety by drawing out lessons to learn from both well managed and poorly managed events
- A structured approach to debriefing has been successfully adopted in a number of fields, including aviation and the military
- Using a structured approach can help make it easier to conduct effective debriefing in healthcare
- Suggested triggers include new clinical experiences, near misses or serious untoward events but also good outcomes in difficult clinical situations
Debriefing is a process through which participants formally reflect on their team performance after a particular task, shift or event. It is well recognised across healthcare and other industries as helpful both in terms of an individual’s own learning and in helping to identify system risks.
Structured approaches can help make debriefing more effective. However, in healthcare there is only limited use of debriefing tools in specific contexts (e.g. DISCERN post-resuscitation).
In June 2014, Dr Cristina Diaz-Navarro and colleagues of Cardiff and Vale University Health Board designed a new multi-professional communication tool, the TALK framework for structured team self-debriefing after unplanned learning events in clinical environments.
The tool is designed to:
- Help early identification of system errors and potential untoward events
- Recognise and encourage successful strategies and behaviours
- Improve communication at a multi-professional level
It proposes an easy way to guide a learning dialogue between team members after a case or clinical session, either when things went well, or when there were near misses or untoward events.
The conversation may be prompted by any team member, but during implementation the developers suggest that each team should identify and agree what situations will prompt its use.
Local implementation is ongoing in Cardiff, initially in the emergency department and within operating theatre teams.
Anaesthetic Incidents Trigger List: a tool to enhance reporting
- Critical incident monitoring is essential for delivery of safe healthcare, but is hindered by significant under-reporting of incidents within all medical specialties, including anaesthesia.
- Developing a trigger list of events provides clarity on what should be reported
- Introducing such a trigger list helped promote a safety culture, improved clinical engagement and has provided data for audit, morbidity analysis and service improvement projects
Laure Martin and colleagues at Craigavon Area Hospital in Northern Ireland wanted to improve the capture rate for incidents in anaesthesia at their hospital, where they felt a reported incidence of adverse events of 1 per 650 anaesthetics was unrealistically low.
They felt that the lack of engagement with reporting stemmed from numerous factors including fear of punitive action, lack of understanding of how the incidents are being analysed, and failure to provide feedback from reports. However they also considered that a lack of clarity over what events should be reported was a significant contributing factor.
Other disciplines have developed lists of 'trigger events' for incident reporting. The Royal College of Obstetricians and Gynaecologists has recommended that each unit should have a local trigger list to help identify risks, as part of its risk management strategy.
Martin and colleagues drew up a list of 93 triggers, defined as events, circumstances or departures from acceptable standards of practice that either could have or did lead to unintended or unexpected harm, loss or damage.
These were grouped together by physiological system, and based on definitions of adverse events published by the Southern Health and Social Care Trust (SHSCT) and national anaesthesia bodies (the Royal College of Anaesthetists and the Association of Anaesthetists of Great Britain and Ireland).
Following the introduction of the trigger list they have seen much higher reporting rates (54 anaesthetic incidents in the year prior introduction of the list, compared to 148 incidents in the first year after introduction and 135 incidents in the second year). Better incident capture has provided useful data for morbidity analysis, department and individual feedback, and has opened the opportunity to audit clinical practice in several areas.
The developers are happy to be contacted on email@example.com to share further information.
Better labelling to reduce the chance of awake paralysis
- The College and Association’s fifth National Audit Project reported 17 cases of ‘drug errors and awake paralysis’, with 11 of these due to syringe swaps.
- Australian data suggests that the most common reported ‘wrong drug’ error was actually giving the wrong drug from a correctly labelled syringe, known as a syringe swap.
- SALG advocates that anaesthetists use the International Colour Coding System for user-applied syringe labels, but currently there is no other way to distinguish between syringes. Could we do more to identify neuromuscular blocking agents after they have been drawn up?
Responding to a pair of incidents where a muscle relaxant was given instead of midazolam, Rachel Williams and Helen Bromhead from Hampshire Hospitals Foundation Trust wanted to do more to differentiate syringes containing neuromuscular blocking agents (NMB) from other drugs.
Using 'Red-Plunger' syringes for muscle relaxants is standard practice in Australia and New Zealand. Using a different syringe colour, rather than just a sticker, has been part of approaches used to reduce the chance of mixing up syringes intended for neuraxial, enteral and intravenous/ intramuscular/subcutaneous use.
Williams and Bromhead found it hard to source alternatively coloured syringes, so instead they designed and adopted colour-coded stickers to apply to the plunger of the syringe in an attempt to replicate a red plunger syringe.
They suggest that this makes the NMB syringe instantly recognisable and clearly differentiates it from other syringes of the same size containing colourless fluid.
This project was featured at the Safe Anaesthesia Liaison Group Patient Safety Conference 2015.