Summary
Anaesthetic equipment plays a central role in anaesthetic practice but brings the potential for malfunction or misuse. We aimed to explore the national picture by reviewing patient safety incidents relating to anaesthetic equipment from the National Reporting and Learning System for England and Wales between 2006 and 2008. We searched the database using the system’s own classification and by scrutinising the free text of relevant incidents. There were 1029 relevant incidents. Of these, 410 (39.8%) concerned patient monitoring, most commonly screen failure during anaesthesia, failure of one modality or failure to transfer data automatically from anaesthetic room to operating theatre. Problems relating to ventilators made up 185 (17.9%) of the reports. Sudden failures during anaesthesia accounted for 142 (13.8%) of these, with a further 10 cases (0.9%) where malfunction caused a sustained or increasing positive pressure in the patient’s airway. Leaks made up 99 (9.6%) of incidents and 53 (5.2%) of incidents arose from the use of infusion pumps. Most (89%) of the incidents caused no patient harm; only 30 (2.9%) were judged to have led to moderate or severe harm. Although equipment was often faulty, user error or unfamiliarity also played a part. A large variety of causes led to a relatively small number of clinical scenarios, that anaesthetists should be ready, both individually and organisationally, to manage even when the cause is not apparent. We make recommendations for enhancing patient safety with respect to equipment.
You can respond to this article at http://www.anaesthesiacorrespondence.com
SummaryNeuromuscular blockade is a powerful anaesthetic tool that has the potential for significant adverse outcomes. We sought to explore the national picture by analysing incidents relating to neuromuscular blockade in anaesthesia from the National Reporting and Learning System from England and Wales between 2006 and 2008. We searched the database of incidents using SNOMED CT Ò search terms and reading the free text of relevant incidents. There were 231 incidents arising from the use or reversal of neuromuscular blocking agents. The main themes identified were: nonavailability of drugs (45 incidents, 19%), possible unintentional awareness under general anaesthesia (42 incidents, 18%), potential allergic reaction (31 incidents, 13%), problems with reversal of blockade (13 incidents, 6%), storage (13 incidents, 6%) and prolonged apnoea (11 incidents, 5%). We make recommendations to reduce human error in the use of neuromuscular blocking agents and on future incident reporting in anaesthesia.
We wish to report two issues that we recently identified following the insertion of a Bivona Õ (Smiths Medical, Ashford, UK) tracheostomy tube which developed recurrent leakage due to cuff deflation. In the first instance, the pilot balloon and cuff were both slowly deflating and required repeated re-inflation. In the second instance (with the same tube), the pilot balloon pressure was elevated, but the cuff continued to have a sizeable leak. On removal and examination of the tube, no structural damage was noted, but the cause for both incidents was identified. The Bivona tracheostomy tube was surgically inserted, and the cuff balloon was initially inflated with air and a good seal was achieved. However, we found a gradual and consistent loss of cuff pressure leading to a loss of tidal volume. The cuff was then re-inflated with air via the pilot balloon and although this resolved the issue temporarily, the cuff leak recurred and the cuff pressure was checked and indicated to be less than 20 cmH 2 O. Assuming this could be due to tube migration, the adjustable flange clip was released and the tube was inserted 1 cm further down the stoma site and the clip was reconnected to its position. The cuff was inflated with air; however, this manoeuvre did not resolve the issue of air leak; examination of the cuff pressure showed a pressure of between 80 and 90 cmH 2 O. The Bivona tracheostomy tube was changed to a conventional size 9.0 Õ Portex (Smiths Medical, Ashford, UK) tube and ventilation improved. Following the removal of the Bivona tracheostomy tube, we had a thorough examination of the tube and found no structural defect or damage to the tube. However, we did find the reasons for the initial cuff leak and the unexpected high cuff pressure.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.