Airway management complications causing temporary patient harm are common, but serious injury is rare. Because most airways are easy, most complications occur in easy airways: these complications can and do lead to harm and death. Because these events are rare, most of our learning comes from large litigation and critical incident databases that help identify patterns and areas where care can be improved: but both have limitations. The recent 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society provides important detailed information and our best estimates of the incidence of major airway complications. A significant proportion of airway complications occur in Intensive Care Units and Emergency Departments, and these more frequently cause patient harm/death and are associated with suboptimal care. Hypoxia is the commonest cause of airway-related deaths. Obesity markedly increases risk of airway complications. Pulmonary aspiration remains the leading cause of airway-related anaesthetic deaths, most cases having identifiable risk factors. Unrecognized oesophageal intubation is not of only historical interest and is entirely avoidable. All airway management techniques fail and prediction scores are rather poor, so many failures are unanticipated. Avoidance of airway complications requires institutional and individual preparedness, careful assessment, good planning and judgement, good communication and teamwork, knowledge and use of a range of techniques and devices, and a willingness to stop performing techniques when they are failing. Analysis of major airway complications identifies areas where practice is suboptimal; research to improve understanding, prevention, and management of such complications remains an anaesthetic priority.

SummaryCommunicating non-urgent, urgent and frank emergency requests for assistance between anaesthetists in theatre often requires a 'go-between' -frequently a non-anaesthetic healthcare professional -to transmit information. We compared the currently recommended situation, background, assessment, recommendation (SBAR) tool with a newly devised Traffic Lights tool ('red alert', 'amber assist' and 'green query') in a simulation study to assess communication quality using 12 validated clinical scenarios of varying urgency. Compared to SBAR, Traffic Lights was used more consistently ('very clear' or 'clear' Traffic Lights 94% vs SBAR 69%); transferred information better (two or three pieces of information correctly transferred Traffic Lights 85%, SBAR 44%; and was judged to lead to greater clarity (all p < 0.0001). Message delivery time was significantly reduced (Traffic Lights 20.5 s vs SBAR 45.5 s, median (95% CI) difference 25 (19-30) s, p < 0.001). Users rated the Traffic Lights system as significantly more useful than SBAR, with 96% of participants preferring the Traffic Lights tool. Results were independent of go-between training. We recommend the adoption of this communication tool as standard practice for anaesthetic teams.

Objectives and BackgroundIntravenous morphine is commonly used in the Emergency Department (ED) and is often prescribed with a dose range from 1 to 10 mg to allow for administration to be titrated to pain. Accurate documentation of the actual dose given or multiple doses given under a single prescription is a legal requirement and is particularly important for a controlled drug. Inadequate documentation may lead to over- or under-dosing, poor handover from ED staff to wards/theatres and raises issues of patient safety, clinical effectiveness and potential medico-legal consequences. We aimed to assess documentation of morphine administration within the ED and evaluate methods for improving practice.MethodsDocumentation of morphine prescribing was reviewed against pharmacy guidelines for a baseline sample of 1200 attendances to our department over a 1-month period. Following staff re-education and protocol dissemination the review was repeated prospectively. After the second review a prescribing sticker was introduced, prompting documentation of the number, dose and timing of morphine boluses given to satisfy each variable dose prescription. A third prospective review was performed.ResultsOverall, 3600 ED attendances were investigated over the three reviews. In 172 cases the drug chart included a variable dose prescription of intravenous morphine. The baseline review showed the actual dose of morphine administered was documented in only 66% of cases. Following re-education and protocol dissemination adherence to pharmacy guidelines rose to 89% and after the introduction of prescribing stickers this increased further to 98%.ConclusionsThe use of a simple drug chart modification and re-education has been shown to improve the documentation of morphine administration to a near perfect level within the ED. Accurate prescribing of controlled drugs is essential and methods such as this can be easily employed to improve patient safety and quality of care.

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