Patient Safety Update:
Past, Present and Future
I was appointed Chair of the Association’s Safety Committee in September 2023 and
represent the Association as Co-Chair of the Safe Anaesthesia Liaison Group (SALG).
Part of my role involves editing the Patient Safety Update so I thought I would take this
opportunity to have a look back at past and present versions of the Patient Safety Update
before describing our plans for the future. The NHS’s journey into modern standards of
patient safety began with an anaesthetist, has had anaesthetic involvement at all stages
and anaesthetists are regarded as exemplars and leaders in this area.
Past
My training in patient safety as an anaesthetic SHO in the
1990s consisted of academic education in preparation for
examinations and listening to the real and apocryphal tales told
to me by consultants as part of my in-theatre apprenticeship.
There was a lot of local knowledge about which were the safest
and most skilled anaesthetists and surgeons, but this rarely
acted upon.
Such information was a deep seam of dark humour for my
contemporary, Phil Hammond, which he used to good effect in
his stand-up comedy routines and his Medicine Balls column in
Private Eye. Phil Hammond also saw the serious side of patient
safety and used his position as a journalist to campaign for the
NHS to the open and transparent
about harm caused to patients.
In 1992, he publicised concerns
raised by an anaesthetist, Stephen
Bolsin about the high mortality rate
from paediatric cardiac surgery
in Bristol Royal Infirmary. Having
worked at the hospital himself
as a junior doctor, he was only
too aware of the difficulty faced
in challenging the established
hierarchy. Despite Stephen
Bolsin’s attempts to escalate his concerns within the hospital,
paediatric cardiac surgery continued until an external
inquiry was started by the Department of Health 1995, led
by Ian Kennedy. This found that there were between 30
and 35 excess deaths in children under the age of one and
produced 198 recommendations to improve patient care.
This and other concerns about Patient Safety led to the
introduction of a statutory duty that ensured that NHS Providers
were accountable for the quality of care in their organisation,
with the establishment of Clinical Governance in 1999.
“Those that fail to
learn from history are
doomed to repeat it.”
Winston Churchill
Despite this it was clear that adverse events were repeatedly
occurring in different hospitals throughout the NHS, with no
mechanism in place to ensure that lessons learned in one
hospital were conveyed to other hospitals. Such adverse events
are often the results of a series of errors or omissions leading to
the critical event itself, as described in Professor James Reason’s
“Swiss Cheese” model of accident causation.
Professor Reason and other clinical and psychology experts
in patient safety co-authored “Organisation with a Memory,”
in 2001 with the Chief Medical Officer, Professor Liam
Donaldson. This report described twelve cases of intrathecal
maladministration of vinca alkaloids, which had been reported
to the Committee of Safety of
Medicines over the previous 16
years, but the true incidence
was unknown as there was no
comprehensive central record of
such events and no opportunity
for the NHS to learn lessons from
these cases. A root cause analysis
presented for one of these
twelve cases showed multiple
failures in safety mechanisms, all
of which could have prevented
the patient’s death. This included administration of intrathecal
chemotherapy by an anaesthetist as the Oncology Senior
Registrar was too busy to come to the anaesthetic room. The
anaesthetist was trained to administer anaesthetic drugs
intrathecally but had no oncology experience and had never
administered chemotherapy before. The anaesthetist injected
vincristine intrathecally in error and the patient died 5 days later.
To ensure that patient safety data was collected centrally, the
National Patient Safety Agency was established in 2001. At this time, each Trust used their own systems for collecting Patient
Safety Incidents, making it difficult to collate information across
the NHS. A data mapping exercise was conducted in 2003, which
allowed input from Local Risk Management Systems such as
DATIX or Ulysses collated from each organisation using agreed
definitions. The NPSA was superseded by the National Reporting
and Learning Service (NRLS) in 2010, with Serious Incidents
reported from 2013 on StEIS, the Strategic Executive Information
System.
Much of the information collected by the NRLS was of great
interest to anaesthetists. NHS England passed relevant incidents
to SALG. In 2011, Isabeau Walker produced the first edition of the
Patient Safety Update for SALG. Editorship passed to Kathleen
Ferguson in 2013, who produced the Patient Safety Update in its
current format until handing over to Tim Meek in 2017, when she
became President Elect of the Association of Anaesthetists. Tim
Meek has since followed in Kathleen’s footsteps by editing PSU,
until he became President Elect in 2023.
Present
For the past 6 years, Tim has curated each edition of the PSU,
selecting vignettes to illustrate incidents of interest, and has
provided expert comments on anaesthetic incidents, ably
assisted by Peter Young, Peter McNaughton and more recently
Peter Hersey for incidents that are more closely related to
intensive care. Peter Hersey is the content curator for the Facultyof Intensive Care Medicine’s own Safety Bulletin, published on
their website since 2020.
For each incident, a vignette is created with colleagues from NHS
Improvement. The amount of detail is dependent upon the data
that comes through NRLS, or via a bespoke anaesthetic eForm
at www.eforms.nrls.nhs.uk/asbreport. This can vary from a few
words to a few paragraphs, with variable levels of information
about the setting, the degree of harm and the outcome.
The SALG website has access to current and previous
editions of the Patient Safety Update back to 2017. In
preparation for my role as Co-Chair of SALG, I conducted a
thematic analysis of all the thirteen currently available editions
on the website, containing almost 250 vignettes. These divide
into several thematic areas that are described in the appendix.
An example of the information collected can be found in the full table online.
The amount of information that comes through the NRLS varies
from a couple of lines to several paragraphs. A paucity of
information can make it difficult for the expert reviewers to make
meaningful comment. The other challenge was that the reports
usually contained information from the initial incident report
and often did not include the results of detailed subsequent
investigations.
Going through all the incidents in detail, I was struck by the
relevance of these cases to my clinical practice. The comments
were helpful and often included the latest safety alerts, national
guidelines, or academic literature on the subject at hand.
Gathered, these rare incidents help to underline the need
for careful preparation, skilled assistance, and pathways of
escalation if complications arise.