Safety in anaesthesia: a study of 12 606 reported incidents from the UK National Reporting and Learning System

Abstract

SummaryThe incident reporting database at the National Patient Safety Agency was interrogated on the nature, frequency and severity of incidents related to anaesthesia. Of 12 606 reports over a 2-year period, 2842 (22.5%) resulted in little harm or a moderate degree of harm, and 269 (2.1%) resulted in severe harm or death, with procedure or treatment problems generating the highest risk. One thousand and thirty-five incidents (8%) related to pre-operative assessment, with harm occurring in 275 (26.6%), and 552 (4.4%) related to epidural anaesthesia, with harm reported in 198 (35.9%). Fifty-eight occurrences of anaesthetic awareness were also examined. This preliminary analysis is not authoritative enough to warrant widespread changes of practice, but justifies future collaborative approaches to reduce the potential for harm and improve the submission, collection and analysis of incident reports. Practitioners, departments and professional bodies should consider how the information can be used to promote patient safety and their own defensibility.

Litigation related to anaesthesia: an analysis of claims against the NHS in England 1995–2007

“…The lag time between clinical event and claim has a median of 1 year but 8% of claims were notified to the NHSLA at least 4 years after the event. In addition, the time from claim to closure, although decreasing, is between 1 and 2 years [9]. Finally inflation needs to be included when trying to compare the cost of historic claims to current claims.…”

“…A recent study analysing more than 12 000 anaesthesia-related clinical incidents notified to the UK NRLS over a 2-year period, also reported that three-quarters of those cases resulted in no harm and only 2% lead to severe harm or death [9]. The authors of that report specifically examined reports associated with epidurals and awareness, but not other clinical categories.…”

“…There are little equivalent data published from the countries of the UK, and no closed claims analysis system exists for anaesthesia, although specialty-specific critical incident analyses have been published [7,8]. A recent publication examined more than 12 000 anaesthesia-related incidents reported to the National Reporting and Learning Service (NRLS) [9], but interpretation and learning from this dataset is hampered by a number of factors which include the enormous number of incidents reported, the fact that most incidents are not reported by anaesthetists, the high proportion of incidents with either low or no patient impact, and a lack of outcome data.…”

An Experience Feedback Committee for Improving Medication Process Safety: An Observational Study in a Hospital Pharmacy Department

“…This included a median of 3 pharmacists [IQR, [3][4] for a median of 1.5 technicians [IQR, 1-2] per meeting. A total of 320 events concerning the pharmacy activities were examined by the EFC with a median of 13 events [IQR, [8][9][10][11][12][13][14][15][16][17][18] per meeting. Events were exclusively (100%) reported by one of the department's professionals.…”

“…It raises awareness of all the possible weaknesses in the care system as well as in the monitoring of the effectiveness of corrective actions [17,18]. Several studies have shown that healthcare professionals, particularly physicians, agree with the importance of incident reporting and the concept of learning from errors [19,20].…”