New proposals to improve safety of anaesthesia

May 10 2004

New proposals to reduce the risk of anaesthetic tubing becoming blocked during operations, were published today. Following 11 similar NHS cases where tubing had become blocked, the Chief Medical Officer, Sir Liam Donaldson set up an Expert Group in July 2002 to look into the issue. The group, chaired by Professor Kent Woods, has now completed its work and produced a new report - 'Protecting the Breathing Circuit in Anaesthesia'.

The report examines the background to the incidents that formed part of Operation Orcadian, a major linked police investigation. It considers technical issues relating to equipment and other relevant matters; behavioural factors; investigating and learning from adverse incidents; and security.

The expert group has concluded that the key elements for avoiding similar incidents in the future are:

• to keep small disposable plastic waste out of areas where patients are being anaesthetised;
• to protect vulnerable patient breathing circuit (PBC) components by keeping them individually wrapped until use; and
• to raise awareness of potential safety issues by guidance, training and clear labelling of the relevant equipment;
• to make sure staff carry out routine checks by guidance and training.

Chief Medical Officer, Sir Liam Donaldson said :

"Thankfully incidents where anaesthetic tubing becomes blocked are rare but when it does happen the outcome can be very dangerous for the patient or even fatal. This is the first time that the risks have been examined in depth.

The Expert Group has made some very practical and achievable recommendations that will significantly help to improve patient safety in this area of healthcare". Professor Kent Woods, Chair of the Expert Group said: "I am pleased to have had the opportunity to chair this Expert Group. This has been a wide-ranging and challenging task.

The Group is aware that much progress has been made in the field of patient safety since the tragic death of Tony Clowes in 2001. However, we have been able to identify a number of new suggestions for improvement in design, wrapping, and storage of devices; training; and security; and to contribute to revised guidance issued by the Association of Anaesthetists of Great Britain and Ireland".

https://www.gov.uk/

The Expert Group's report is available at www.dh.gov.uk/publications.
The Association of Aneasthetists of Great Britain and Irelands guidance is available at https://anaesthetists.org/