Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment

We sent a letter (15 May 2023) to the deans of all UK medical schools, co-signed by the Medical Schools Council and the UK Foundation Programme Office, to explain that this amendment is needed to mitigate risks to patients, and we will therefore implement this recommendation as soon as is practically possible. To support this, we requested all medical schools respond to a set of questions that would enable us to determine an appropriate amendment and timelines for the change to be implemented locally by medical schools. We understand that local implementation by medical schools will involve communicating the amendment to educators and learners, as well as updating learning materials and documentation. This letter also outlined our plans to use the quality assurance self-assessment questionnaires medical schools complete annually to confirm that the amendment has been implemented locally. In response to this letter, we have received strong support for making an amendment to the list and for this to have been implemented locally by medical schools in time for the 2023-2024 academic year. A second letter will be sent to all UK medical schools confirming the specific amendment that will be made and requesting this is locally implemented in time for the new academic year. We will then publish an updated version of the Outcomes for graduates - Practical skills and procedures (2019) on our website and communicate this through relevant channels. Actions planned to deliver safety recommendation: GMC to write to all UK medical schools confirming the amendment it will make to the practical skills and procedures list and its expectations for when medical schools should implement this locally, by July 2023. GMC to publish updated Outcomes for graduates – Practical skills and procedures on its website and communicate the change through relevant channels, by August 2023. GMC to confirm the amendment has been implemented locally by all medical schools through the annual self-assessment questionnaires all medical schools complete, by October 2023 - December 2024. Response received on 23 June 2023.

A new version of Good medical practice (2013), which describes the professional behaviours expected of all doctors registered with the GMC, is to be published imminently. This will enable us, in conjunction with the Medical Schools Council (MSC), to begin our review of Achieving good medical practice: guidance for medical students (2016), which shows how the principles and values of Good medical practice apply to medical students. Through this work we will determine how best to include the type of guidance specified in this safety recommendation. We have sent a letter (15 May 2023) to the deans of all UK medical schools, co-signed by the Medical Schools Council, setting out our plan to have updated this document and implemented this safety recommendation by the end of Quarter 1 2024. This letter also outlined plans to use the quality assurance self-assessment questionnaires medical schools complete annually to explore questions in relation to the safeguards that are in place for medical students on clinical placements. We will also use the next medical student professionalism competition, which we run with the MSC, to focus on the importance of learners always working within their competence. This will promote awareness of this issue. Actions planned to deliver safety recommendation: GMC and MSC to review Achieving good medical practice: guidance for medical students, by August 2023 - April 2024. GMC to publish updated Achieving good medical practice: guidance for medical students, by April 2024. The GMC and MSC will run the next student professionalism competition on topic of students working within their competence, by June - October 2023. The GMC will explore questions around safeguards for medical students on clinical placements through annual quality assurance self-assessment questionnaires, by October 2023 - December 2024. Response received on 23 June 2023.

We have considered HSIB’s investigation report relating to the safety risk of air embolus associated with central venous catheters used for haemodialysis treatment and noted the specific recommendation made to us. Air ingress due to unclamped catheters is an avoidable safety risk and further communication may help reducing the number of occurrences; we have therefore updated the MHRA Dialysis Guidance to raise awareness of the importance of clamping and capping central venous catheters. Action carried out to deliver safety recommendation response: Update of the MHRA Dialysis Guidance (2022) in quarter 2, 2023, to include risk of air embolus associated with unclamped haemodialysis catheters. Response received on 18 July 2023.