1. Easier Reporting of Anaesthetic Incidents

2. Aims of Today Inform participants of the development and use of the eForm Discuss specialty engagement through anaesthetic reporting and feedback Discuss engagement and implementation ideas to take back to your organisations

3. What is the National Reporting and Learning Service? Owns and maintains a database to which patient safety incidents are uploaded Spots patterns and trends in risks Accessible to all NHS staff in England and Wales to report to (via LRMS or directly) Complements local safety reporting systems Provides safety recommendations to the NHS Working on ways of engaging clinicians to help influence the most effective way to use data

4. Summary of RLS Data Almost 4 million incidents received Currently around 83,000 incidents monthly Approx 6,000 medication incidents monthly Jan 2010

5. The NPSA Learning Cycle The Reporting & Learning Service enables the NHS to understand why, what and how patient safety incidents happen, learn from these experiences and take action to prevent the occurrence of future harm to patients. It does this through a serious of processes which collect, review, analyse and feed back data, learning and action relating to patient safety risks to support local patient safety improvement activities.

6. Type of anaesthetic incidents (NRLS) November 2003 – February 2006

7. Severity of anaesthetic incidents (NRLS) November 2003 – February 2006

8. 1,700 incidents from1 st August 2005 to 31 st August 2008 60% reported in Theatres or ICU 5% reported in Recovery 4% reported in Anaesthetic Room Medication incidents in Anaesthesia

9. Reported Degree of Harm 76% - no harm 18% - low harm 4% - moderate harm 1% - severe harm or death

10. Stage in medication process of incidents reported in anaesthetic specialities compared to all specialities Medication incidents reported August 2005 to July 2008

11. Type of medication incidents reported in anaesthetic specialties compared to all specialities Medication incidents reported August 2005 to July 2008

12. Greater focus on the Reporting and Learning System (RLS) Simplify and encourage reporting of safety incidents More rapid reporting (36 hours) and more rapid learning Capture risky situations Make data more useful to stimulate change locally Engagement with clinicians

15. Safe Anaesthesia Liaison Group (SALG) Terms of Reference Extract To build a close relationship with the NHS Trusts involved in (piloting) the reporting system. To review anaesthesia specific incidents reported to the NPSA To provide periodic reports for wider dissemination and to assist in establishing action, training and education needs To evaluate anaesthesia safety reports for further investigation, research or audit.

16. SALG Outcomes Enhanced patient safety Raising awareness - engaging profession Guidelines/recommendations/NPSA alerts Professional standards NIAA – audit, research Training Examinations

17. Safe Anaesthesia Liaison Group (SALG) Core members 2 RCoA representatives 2 AAGBI representatives 2 NPSA representatives Co-opted members Individual consultants with track record Named individuals representing ODP’s, nurses and midwives Named individuals from specialist societies Other named individuals including PLG and MHRA

18. SALG: Reporting to Learning Rapid response Immediate consultation NPSA – RCOA – AAGBI Supporting drafting Rapid Response Report Further consultation –Colleges, Specialist Societies and Associations Rapid Response Report Dissemination via NPSA, RCOA and AAGBI mechanisms

19. SALG: Reporting to Learning Dissemination of other data Trusts / Departments Websites NPSA, RCOA, AAGBI, Specialists Societies, AfPP, CODP Journals Newsletters Bulletins

22. The Anaesthetic Project Two year project Led by RCoA/AAGBI Supported by NPSA Anaesthesia: Improvement through partnership

23. Speciality Specific Reporting in Anaesthesia Provide RCoA and AAGBI with access to data Allow RCoA and AAGBI to provide rapid feedback on ‘high priority’ incidents Clinicians undertaking analysis Shared learning locally as well as nationally Further engaging the anaesthetic profession in reporting patient safety incidents

24. Developing the eForm and the Process Design a specialty based reporting form Test a data classification/taxonomy to support the way anaesthesia related incidents are reported to the NPSA Place an initial focus on the reporting of incidents during the surgical pathway by all members of the team Provide access to clinical experts at RCOA and AAGBI to discuss incidents and determine further action if required Test the system in a select number of acute trusts in England and Wales

25. DESIGNED BY ANAESTHETISTS FOR ANAESTHETISTS ANALYSED BY ANAESTHETISTS FEEDBACK TO ANAESTHETISTS REPORTED BY ANAESTHETIC TEAMS

26. Anaesthetic eForm and LRMS reports National Reporting and Learning System (RLS) Secure Database Data cleansing Cleansed Database RCOA AAGBI and NPSA clinicians from SALG review weekly deaths and severes with NPSA.All other eForm data will be reviewed quarterly for themes and relevancies Rapid responses, Alerts, safety notices share with networks

27. Feedback ‘ There is an issue of trust. Some people feel that reporting will be used against them’ ‘I reported a patient who became hypertensive because it was a classical fixation error which had a learning message’ ‘There are every day occurrences, such as a difficult intubation, problems with the anaesthetic machine, patient with hypertension, which we have to deal with as part of our work and I would not expect these to be reported’ I am more likely to report if it is anaesthesia specific’ ‘Some don’t think there is any point reporting as they get no feedback‘’

28. Key Learning from Pilot Evaluation Concerns from risk managers that speciality reporting should not undermine local clinical governance structures 50% of reports were submitted within 24 hours of the incident and 87% within a week Some medical staff prefer a speciality reporting route to a local risk management system Quality of incident reports good Anaesthetists are likely to be motivated to report if it will contribute to learning locally and nationally, but the recognised barriers to reporting remain Teams need to know what should be reported

29. We are concerned that there remains significant under-reporting, particularly in respect of incidents in primary care; medication incidents; serious incidents; and reporting by doctors The “one size fits all” nature of reporting systems is also a significant problem. We welcome the NPSA’s recognition of the need to address this by developing reporting systems that are appropriate to different specialties (such as general practice and anaesthesia).

30. Patient Safety Alert: NPSA/2009/PSA003 Being open November 2009 The benefits of Being open are widely recognised and supported by policy makers, professional bodies and litigation and indemnity bodies, including the Department of Health, General Medical Council (GMC), National Health Service Litigation Authority (NHSLA), Medical Defence Union (MDU) and the Medical Protection Society (MPS) “The NHS also commits, when mistakes happen, to acknowledge them, apologise, explain what went wrong and put things right quickly and effectively.”

31. Next steps for speciality specific reporting in anaesthesia Roll out as part of Patient Safety Direct eForm nationally available Local workshops to engage risk managers and clinicians Information packs and FAQs available on web Articles in Anaesthetic Journals Identification of Anaesthetic Champions Continuing development of SALG

32. The eForm and how to use it

33. What happens next? eForm submitted Immediately encrypted and emailed to ‘share with organisation’ email address ‘share with organisation’ address must be: - Working - Accessible The attached encrypted information needs to be saved, prior to going to the RLS extranet page

37. What is a patient safety incident and what should I report ? Any unintended or unexpected incident that could have or did lead to harm for a patient receiving NHS healthcare Any anaesthesia-related incident occurring in the surgical pathway. Any anaesthesia-related incident occurring during a planned anaesthetic for a diagnostic or non surgical intervention. Near misses that could result in a patient safety incident leading to harm

38. Example Vasoactive drugs drawn up by (name) ampoules checked as appropriate i.e. metaraminol, phentolamine and GTN. Labeled syringes found to be phentolamine, GTN, GTN. Drugs discarded and drawn up again. Near miss potential harm moderate

39. Example Laparoscopic gynaecological surgery took 5 hours head down. Patient woke unable to move right arm because of pressure from being head down with shoulder T bars. Severe

41. Implementation advice It is not usually the “what” that scuppers implementing great ideas but the “how”. Jane Reid Intervention Lead (Perioperative)Patient Safety First Campaign

42. There is another way “ Stack the cards in your favour” (Segmentation) Start in an area that is receptive to change, choose carefully.

43. Successful introduction of anything new in a large organisation requires at the outset to: Directly engage the people who will be using it and connect with the “will” and energy of local champions and others who want to change things. That is why we are all here Encourage testing different ways of doing it to fit different contexts and circumstances We will be spending time in groups to discuss how it will work in your organisation and how you are going to take this information back. Even if you will not be using this system( i.e;you have a robust incident process) this should stimulate debate on how to increase/improve incident reporting in your organisation

44. Successful introduction of anything new in a large organisation cont… Encourages people to come up with their own ideas for increasing effectiveness and reliability You have the information and now the opportunity to discuss with your colleagues your ideas – (e.g. start small then review) Promote networking, sharing and learning amongst colleagues and peers both internally and across organisational boundaries. Attending today will provide the opportunity to access senior clinicians and NPSA and fellow colleagues to discuss reporting and learning from anaesthetic incidents for the future and benefit patient safety Provide support through information, improvement skills and leadership. Information on website, feedback from your specialty (SALG), feedback from you to your organisation, renewed interest in reporting

45. Group Work How could it work in your organisation? Is your organisation a “high reporter”? What feedback do you get locally or nationally?what would be better? Would the eForm contribute to your local governance procedures? What would be the best way of introducing it to your organisation and colleagues? What will be your biggest barriers?

46. Questions to Panel

47. Further information National Reporting and Learning Service, NPSA http://www.nrls.npsa.nhs.uk ‘Seven steps to patient safety’ ‘Being open: communicating patient safety incidents with patients, their families and carers’ The Royal College of Anaesthetists www.rcoa.ac.uk Smith AF, Mahajan RP. National critical incident reporting: Improving patient safety. Br J Anaesth. 2009; 103:623-625

48. Information The presentation and all the supporting information we have referred to will be emailed to your contact address you have provided within a short timescale to be advised