Residual drugs in intravenous cannulae and extension lines — HSSIB Investigation

Summary

2 recommendations 3 observations 15 learning prompts 2 of 2 responded

Safety Recommendations

2 total

R/2021/115 Royal College of Anaesthetists

HSIB recommends that the Royal College of Anaesthetists and Centre for Perioperative Care work with relevant stakeholders - such as the Association of Anaesthetists, College of Operating Department Practitioners, and Association for Perioperative Practice - to review, update and integrate new guidance on the surgical safety checklist 'Sign Out' process. Specifically, the guidance should be updated in relation to the flushing of cannulae and extension lines by strengthening the current administrative barriers, considering the hierarchy of hazard control, and the issues identified by the HSIB investigation.

The RCoA and CPOC will work with stakeholders to update the surgical safety checklist 'Sign-Out' process via CPOC's National Safety Standards for Invasive Procedures, and embed this guidance nationally.

Response received 14 May 2021

The Royal College of Anaesthetists and the Centre for Perioperative Care welcome the publication of the Healthcare Safety Investigation Branch’s (HSIB’s) report on residual drugs in intravenous cannulae and extension lines and supports the recommendations made to the College. The College will work with the Centre for Perioperative Care (CPOC) and other key stakeholders to update and modify the surgical safety checklist ‘Sign-Out’ process through CPOC’s National Safety Standards for Invasive Procedures. The College will then promote adoption of the modified process through the Safe Anaesthesia Liaison Group and embed the guidance within our accreditation scheme to ensure its application nationally. Response received on 14 May 2021.

R/2021/116 Royal College of Anaesthetists

HSIB recommends that the Royal College of Anaesthetists reviews its 'Guidelines for the provision of anaesthetic services' regarding the planning and oversight of perianaesthetic care in non-theatre settings. This should include: guidance to assist anaesthetic departments to consistently plan for short-notice or emergency cases which take place in the non-theatre setting planning which considers and mitigates against unexpected changes in conditions.

The Royal College of Anaesthetists will address the recommendations regarding planning and oversight of perianaesthetic care in non-theatre settings when its Guidelines for the Provision of Anaesthesia Services are reviewed later this year.

Response received 14 May 2021

The College updates our Guidelines for the Provision of Anaesthesia Services (GPAS) on an annual basis. The recommendations from this report will be addressed when the relevant GPAS chapters are reviewed later this year. Response received on 14 May 2021.

Safety Observations

3 total

Observation 1 Observation It may be beneficial for healthcare trusts to adopt the programme provided by Health Education England for intravenous (IV) skills, which supports the competency requirements published by the Nursing and Midwifery Council.

Observation 2 Observation It may be beneficial to increase the use of body maps to record the presence of all indwelling items, such as cannulae, catheter and drains, during an anaesthetic procedure. The body map could be used as part of an enhanced sign-out and to provide instructions for the management of each indwelling item in the postoperative period.

Observation 3 Observation It may be beneficial for manufacturers to further standardise product specifications to design out the potential for errors. For example, items such as Y-connectors, extension lines and needle-free connectors often look similar but may have differing specifications.

Learning Prompts

15 total

Prompt 1 Learning prompt One of the key risk factors associated with residual drugs in cannulae and extension lines is the concentration and risks associated with the drug itself.

Prompt 2 Learning prompt This is particularly the case for drugs that can cause a clinically significant effect in low volumes.

Prompt 3 Learning prompt Flushing is a key mitigation for preventing the risk of residual drugs in cannulae and extension lines. However, it sits at the ‘administrative controls’ level of the hierarchy of hazard control, towards the ‘least effect’ end of the control spectrum ( see figure 7 ).

Prompt 4 Learning prompt There are issues associated with the design of IV equipment which increase the risk of residual drugs in cannulae and extension lines. There may be opportunities to improve equipment design to design out the potential for errors. The unintended consequences of redesign would need to be considered.

Prompt 5 Learning prompt Where certain drugs are used during an anaesthetic, such as NMBAs and some strong opioids, flushing becomes a safety-critical task. However, the task of flushing is functionally the same and there are limited additional steps or process alterations that mark the flushing of a consequential drug versus flushing to maintain the flow of fluid through a cannula.

Prompt 6 Learning prompt The WHO surgical safety checklist is an administrative control used to mitigate residual drugs in cannulae and extension lines following anaesthesia. Items on the WHO checklist act as prompts for expected actions or tasks, and do not include second/independent checks or other hazard control activities proportionate to the risks being addressed by the process.

Prompt 7 Learning prompt Greater attention and focus are given to the Sign In and Time Out phases of the WHO checklist compared to Sign Out. The Sign Out process appears to compete with other tasks and processes and is often rote-learned and anticipated. This presents the risk that the purpose of the checklist is lost, and safety-critical checks overlooked.

Prompt 8 Learning prompt There is variation between IV devices and associated equipment. Many of these devices appear outwardly similar but, according to manufacturers’ information, have variable specifications relating to the potential for regurgitation.

Prompt 9 Learning prompt Consumable IV equipment may be subject to change for a range of reasons which may include availability, cost, newer/better variants, and quality. Training and awareness of these changes is rarely provided, but there is a risk that staff are not made aware of changes to specification and/or device performance.

Prompt 10 Learning prompt Healthcare trusts acted upon the epic3 guidelines to minimise the number of ports on cannulae several years ago. The change management process at the time did not consider a wide range of stakeholders, including the end users.

Prompt 11 Learning prompt Healthcare providers are required to reduce the instances and risk of hospital acquired infections. The introduction of non-ported cannulae was not effectively communicated to end users and this affected the introduction of these items.

Prompt 12 Learning prompt In adult care, administration of flushes is rarely reconciled or recorded on perioperative documentation.

Prompt 13 Learning prompt Patients with multiple IV access sites are believed to be at greater risk of residual drugs in cannulae and extension lines. Recording of IV sites is not consistent.

Prompt 14 Learning prompt Paediatric anaesthetic practice differs from adult practice as flushes are prescribed and reconciled due to the specific additional considerations when anaesthetising very small children.

Prompt 15 Learning prompt Many of the hazard controls currently used to reduce the risk of residual drugs in cannulae and extension lines sit at the ‘administrative controls’ and less effective levels of the hierarchy of hazard control. The investigation considered that there may be stronger and more effective solutions that could be put in place. For example, physically removing the hazard (the drug) from clinical practice, replacing the hazard with a less hazardous drug, or reducing the concentration of the drug.