Time for mandatory safety preparedness: a responsibility for individuals, hospitals and national bodies

Abstract

Most of the time, anaesthesia in the UK is practiced and delivered safely. However, emergencies or serious complications associated with anaesthesia do occur, with potentially devastating consequences for patients, their families and staff. Although anaesthetic emergencies are usually managed well, national reports consistently identify room for improvement. For example, despite high-profile cases, unrecognised oesophageal intubation still occurs in the UK, causing harm (including death) and is preventable [1].

Data from the 7th National Audit Project (NAP7) have shown anaesthesia and surgery to be very safe (risk of death during elective surgery if a patient is of ASA physical status 1–2 is around 1 in 100,000 cases) but also that life-threatening events are not that uncommon (one or more potentially serious complications in 1 in 18 cases, cardiac arrest in 1 in 3000 and close to 1 in 1000 in patients who are older and frailer) [2]. More than half of cardiac arrests are caused by low occurrence, high impact events (haemorrhage, severe bradycardia, cardiac ischaemia, isolated hypotension, hypoxaemia and anaphylaxis) [3]. Unrecognised oesophageal intubation remains an unmeasured and too prevalent problem. Care was often imperfect, being judged (when assessable) to include poor care in 40% of cases before the event and in 36% of cases overall.

It is too easy to believe that rare things do not happen to us or our patients, but this view could not be further from the truth. The approximately 24,000 cases reported to the NAP7 activity survey are comparable in volume to the annual throughput of some larger NHS sites. Based on that survey data and from NAP4 4 and NAP6, these centres would see a case of profound hypotension five times a week, two major haemorrhages a week, laryngospasm every other day, aspiration twice a month, 2–3 life-threatening anaphylactic reactions a year, eight cardiac arrests and several peri-operative deaths [2, 3]. Emergencies are happening all around us. Even if they do not happen to the patient directly under our care.

Nathanson et al. call for mandatory training to focus on low occurrence, high impact events [4]. Many of these have been the focus of previous National Audit Projects. Many may consider the view of Nathanson et al. the right thing to do, but it may not be universally popular and would represent a revolution in mandatory training in the UK. There have already been calls for significant overhauls of mandatory training [5]. What is mandatory, what is statutory and what is fruitful, do not always overlap. However, what needs to be designed, delivered and implemented must be just right; effective but not burdensome. It must be built from solid evidence and be of value and not tokenistic.

An important challenge arises regarding who should drive such a change. The Royal College of Anaesthetists takes the view that it cannot mandate the actions of its members but, conversely, it holds the baton for professional standards, and must, therefore, take a lead. The Association of Anaesthetists has a long history of promoting safety and improving standards through guidelines. We recommend that a task force is established by the College and Association. The NHS should be centrally engaged and committed. Representation from specialist societies, surgeons, patients and experts in human factors, education and implementation science will be essential. The core emergencies should be agreed on and delivery modalities tested. It must be adequately funded, and the efficacy rigorously evaluated. Lessons should be learnt from Australia and New Zealand, where such a programme already exists, and any programme should apply to the NHS and the independent sector. Only through a genuine commitment (nationally, by organisations and departments) to maintain a level of preparedness for anaesthetists, teams and departments can we manage these low occurrence, high impact events better and improve patient safety.