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National Patient Safety Agency

Better reporting and learning encouraged in Anaesthesia

29 September 2008


Anaesthetists and other clinical staff throughout England and Wales may soon have access to a specially designed system where they can report patient safety incidents and “near misses”.


Today (Monday 29th September) the National Patient Safety Agency (NPSA) and Royal College of Anaesthetists (RCoA) are hosting an event to detail the findings so far of a new pilot scheme for reporting and learning from Anaesthesia-related incidents, as part of the NPSA’s National Reporting and Learning System. Speakers will include the Chief Medical Officer Sir Liam Donaldson, the Presidents of the RCoA and the Association of Anaesthetists of Great Britain and Ireland (AAGBI) and NPSA Chief Executive Martin Fletcher.


The system has been jointly developed by the NPSA, RCoA and the AAGBI. It has been piloted in thirteen NHS trusts across England and Wales since May this year.


Anaesthetists and other clinical staff are encouraged to fill in a confidential online form every time an incident occurs concerning the safety of a patient. Clinical safety experts analyse these reports to identify patterns of risk and ways of making Anaesthesia even safer. Feedback will be widely circulated through professional networks of the RCoA and AAGBI and other routes.


If the pilot is well-received the NPSA, RCoA and the AAGBI hope to then extend the speciality-based system across further NHS trusts in England and Wales to improve learning from the incidents reported.


Speaking  of  the  speciality-based anaesthetic reporting system pilot, Sir Liam Donaldson, Chief Medical Officer said:


“The  most  important knowledge in patient safety is how to prevent harm to future patients. Building a deeper understanding of the unique risks within different  clinical  specialties  is an essential part of this knowledge. I commend  the  College,  Association  and  NPSA on this important initiative which will further strengthen the National Reporting and Learning System as a  foundation  of  our  efforts  to  improve  the  safety  of  patient care everywhere.”


Speaking of the speciality-based anaesthetic reporting system pilot, Martin Fletcher, Chief Executive of the NPSA said:


“This pilot builds on the strong commitment of the Anaesthesia profession to provide the safest possible care to patients. Our close partnership with the College and the Association has been a particular strength of this initiative.


“By continuing to promote better reporting – and making sure we respond to what we learn – we will establish a more complete picture of the patient safety issues we face and ensure that safety priorities focus on where action is most needed.”


Speaking of the pilot, Professor Ravi Mahajan council member the Royal College of Anaesthetists and chair of the two year “Anaesthesia: Improvement through Partnership” project said:


“Creating a specialised system for anaesthetic reporting has been an aim of the Royal College for some time now. We hope that this project will establish a clearer understanding of the major issues in Anaesthesia, which is the largest acute specialty in the NHS. If the pilot is successful we hope that other specialties will follow our lead, in collaboration with the NPSA.”


Speaking of the pilot, Dr Richard Birks, President of the Association of Anaesthetists of Great Britain and Ireland said:


“Last year the Association celebrated its 75th Anniversary; “75 years of advancing patient safety” was the strap line. This new initiative with the NPSA will continue that process.”


The pilot is due to end in September, after which the data will be evaluated before wider implementation is considered.


Further information




Notes for editors:


  1. Media enquiries to Paul Cooney in the NPSA Press Office on 020 7927 9351 or paul.cooney@npsa.nhs.uk. Out of hours call 0788 411 5956.
  2. The speciality-based anaesthetic reporting system pilot event will be held at the Royal College of Anaesthetists on Monday 29 September. There is limited capacity for media attendance. If you are a journalist and would like to attend, contact Paul Cooney on 020 7927 9351.
  3. The speciality-based anaesthetic reporting system is part of the two year “Anaesthesia: Improvement through Partnership” project led by the NPSA and RCoA. It marks the first time that the NPSA has worked in partnership with Colleges and professional organisations in the reporting and learning of patient safety incidents. While data reported onto the speciality-specific e-forms will feed into the NPSA’s wider database for patient safety incidents (the Reporting and Learning System) , the RCoA and AAGBI will only have access to the anaesthetic data so that they can have a direct role in the analysis of incidents and promote shared learning through their networks.
  4. A patient safety incident is any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS-funded healthcare. Pilot sites are being encouraged to report all Anaesthesia-related patient safety incidents that occur in the surgical pathway to the speciality-based system. These incidents can range from direct problems with administering the anaesthetic or removing the cannula, allergic or unexpected reactions, accidental disconnection from the anaesthetic, to more general incidents that can impact on the anaesthetist’s ability to perform, such as poor quality notes, lack of available beds or poor communication with staff.
  5. The National Patient Safety Agency encompasses the National Research Ethics Service, National Reporting and Learning Service and the National Clinical Assessment Service. Our vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations. Each division works within its sphere of expertise to improve patient outcomes.