Critical incident reports concerning anaesthetic equipment: analysis of the UK National Reporting and Learning System (NRLS) data from 2006-2008*

Abstract

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

Unexpected anesthetic leakage from a damaged O-ring on the Selectatec back bar -A case report-

“…The most common locations of a leak are the low pressure system, breathing system, or around endotracheal tube [3].…”

Critical Incident Analysis: Equip to Avoid Failure

“…Fasting and Gisvold (2002) suggested that 25% of equipment problems could be related to human error and furthermore that 18 of 29 cases were related to inadequate pre-use checks. Cassidy et al (2011) argued that it may be easier for a clinician to blame the equipment rather than to admit a misunderstanding or mistake. A 'human factors' approach (Reason 1990) can be utilised to focus on the organisational factors that led to the incident which occurred, rather than zoning individual blame (Mahajan 2010).…”

“…The factors included an inadequate skill mix and the competency of staff, including the specialist anaesthetic nurse who had to troubleshoot technical issues with the anaesthetic equipment. Cassidy et al (2011) drew attention to the National Patient Safety Agency (NPSA) which since 2006 has worked closely with clinicians in an attempt to extract useful lessons from incidents and to translate them into improvements in clinical practice. Since April 2016 a National Reporting and Learning System (NRLS) in the UK has been under the umbrella of NHS Improvement.…”

“…RCA helps to interlink the contributing factors and analyses how the incident occurred, providing suggestions to improve the system for the future. Specialised equipment plays a central role in anaesthetic practice; an unintended consequence is the potential for malfunction or misuse (Cassidy et al 2011). The context of the critical clinical incident described below was an operating theatre department.…”

A signal enhanced portable raman probe for anesthetic gas monitoring

“…Since various independent sensors are used, the total gas concentration may differ from 100 vol.% e.g. if one sensor is miscalibrated, this can lead to conflicting information increasing the potential for a wrong decision of the caregiver [7,8]. A further disadvantage of conventional systems is the need for treatment of the gas sample like e.g.…”