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5-step Risk-management Cycle (modern Patient-safety model)
| Step | Key aim | Theatre-level examples |
|---|---|---|
| 1 Risk awareness | Recognise that peri-operative care is a complex, high-risk system requiring constant vigilance. | Safety huddles, pre-list brief, Friday M&M “good catch” slot. |
| 2 Risk identification | Detect specific hazards (prospectively or retrospectively). | SWARM walk-round, incident reports, HFMEA for new IV pump. |
| 3 Risk assessment | Estimate likelihood × consequence; record on risk register. | Use NHS/SA DoH 5 × 5 matrix: airway fire = rare/catastrophic → score 15. |
| 4 Risk control / management | Eliminate, substitute, engineer, admin, PPE (hierarchy). | Switch from reusable to single-use laryngoscope blades; SOP updates; staff training. |
| 5 Re-evaluation | Continually review controls; measure effectiveness. | Quarterly audit of airway equipment contamination; update register. |
- Tip: keep the departmental risk register live on SharePoint with owner, score, mitigation & review date for each risk.
Practical toolkit–assess ▸ Manage ▸ Evaluate
| Assess | Manage | Evaluate |
|---|---|---|
| • Trend analysis of incidents & complaints • Staffing & workload review • Skin-integrity, falls & VTE scores |
• Remove/avoid hazard • Create protocol + simulation • Specialist equipment (e.g. low-air-loss mattress) • Mandatory training compliance |
• Clinical audit • Benchmark (e.g. NELA, ICNARC) • Safety-climate survey • Health-and-safety inspection |
Root-cause Analysis (RCA)–four Structured Stages
| Stage | What you do | Tools |
|---|---|---|
| I Data collection | Gather records, protocols, switchboard logs, staffing rotas, CCTV, witness statements. | Doc box, secure e-folder. |
| II Information display | Build timeline–narrative, tabular or swim-lane chart. | Canva, Miro. |
| III Root-cause identification | • 5 Whys (ask “Why?” until system factor revealed). • Barrier analysis–physical ▶ natural ▶ human ▶ admin. |
London Framework, Ishikawa fishbone. |
| IV Recommendations & implementation | Convert findings into SMART actions; assign owner & deadline; feed into risk register. | Action tracker with RAG status; close-the-loop meeting. |
Everyday-risk Guide for Consent Conversations
- Link anaesthetic risks to familiar daily activities–helps patients contextualise probabilities.
| Everyday risk category | Risk band | Anaesthetic example |
|---|---|---|
| Negligible (< 1: 1 000 000) | Lightning-strike death | Fatal aspiration (1: 350 000) |
| Minimal → very low (1: 100 000–1: 10 000) | Rail accident death | Anaesthesia mortality healthy ASA I (1: 100 000) |
| Low (1: 1 000–1: 10 000) | Traffic-collision death | Peri-op cardiac arrest (1: 3 000) |
| Moderate (1: 100–1: 1 000) | Death from natural causes age > 40 | Laryngospasm adult (1: 110) |
| High (> 1: 100) | Diarrhoea after antibiotics | PONV (20-30 %), moderate pain (50 %) |
- (Use local audit data where available to refine figures.)
Selected Complication rates–2024 Evidence
| Adult GA complication | Incidence | Category |
|---|---|---|
| Severe anaphylaxis (NAP 6) | 1: 10 000 | Very low |
| Peripheral nerve injury permanent | 1: 1 000 | Low |
| Awareness with recall | 1: 19 000 (NAP 5) | Very low |
| PONV | 20-30 % | High |
- Paediatric, neuraxial and nerve-block tables unchanged–verify with local incidence every 2 years.
NAP Summaries
| NAP # | Years & data set | Focus | Design / scale | Headline incidence | Practice-shaping messages |
|---|---|---|---|---|---|
| NAP1 | 2003 (nation-wide questionnaire) | Supervisory role of consultant anaesthetists | Survey of all UK departments on levels of trainee supervision | Described wide variation; up to 25 % of trainees sometimes unsupervised on call | Triggered named-supervisor policies and “immediately-available consultant” rota standards. |
| NAP2 | 2003 (questionnaire & case review) | Effectiveness of Mortality & Morbidity (M&M) meetings | National snapshot of structure, attendance and learning output | Only 58 % of departments had a formalised M&M process; minutes rarely fed into hospital governance | Led to mandatory, min-monthly, minuted M&M linked to the risk register. |
| NAP3 | Sept 2006–Aug 2007 | Major complications of central neuraxial block | Prospective case capture + parallel activity survey in >300 hospitals | Permanent harm after CNB: 1: 23 000 (epidural); spinal haematoma 1: 320 000 (atraumatic) | Emphasised early MRI & decompression; introduced 24 h CNB hotline and consent leaflets. |
| NAP4 | Sept 2008–Aug 2009 | Major complications of airway management (anaesthesia, ICU, ED) | Prospective registry of ≥ 48 h morbidity or death; 95 % UK hospitals | Serious airway complication: 1: 22 000 general anaesthetics; 46 % in ICU/ED | Universal continuous capnography outside theatre; formal FONA algorithm (scalpel-bougie). |
| NAP5 | June 2012–May 2013 | Accidental awareness during general anaesthesia (AAGA) | Nationwide two-phase reporting + 16 000-patient incidence survey | Definite/probable AAGA 1: 19 600; 2 × higher with muscle relaxant without depth monitoring | Depth-of-anaesthesia (pEEG) advised when neuromuscular blockade used; new consent wording for AAGA risk. |
| NAP6 | Nov 2015–Nov 2016 | Peri-operative anaphylaxis | Prospective capture of grade 3–5 reactions during 3 million anaesthetics | Incidence 1: 10 000; 47 % antibiotics, 33 % NMBAs, chlorhexidine 9 %; 96 % survival | Teicoplanin 17× risk vs cefazolin → switch first-line prophylaxis; mandatory adrenaline 1 mg/10 mL pre-filled syringes in every OR. |
| NAP7 | 16 Jun 2021–15 Jun 2022 | Peri-operative cardiac arrest (POCA) | All UK & Ireland NHS/independent hospitals; 881 arrests from 2.71 million cases | POCA incidence 1: 3 000; 50 % within 10 min of induction; ROSC 62 %, survival to discharge 44 % | Early epinephrine (< 2 min) doubles survival; routine CO₂ waveform and team “CPR pre-brief” now in GPAS standards. |
| NAP8 (in progress) | 2024–2026 (recruiting) | Major complications of regional anaesthesia & peri-operative nerve/spinal cord injury | Will combine incident reporting with denominator activity census | – | Local co-ordinators being appointed; interim advice: meticulous block documentation, real-time LAST rescue kit. |
Links
Past Exam Questions
Critical Incident Reporting in the Hospital Setting
In the last few years, there has been a paradigm shift to improve critical incident reporting in the hospital setting.
a) What is your understanding of a critical incident, and why should it be reported? (2)
b) List 4 interventions that you, as a manager, will employ to ensure an effective critical incident reporting system. (4)
c) In South Africa, what are the pitfalls/challenges to the success of an effective incident reporting system? (4)
References:
- Part II Anaesthesia Refresher Course – 2011 University of Cape Town Risks of Anaesthesia Dr. R Haylett
- Bould, M. D., Hunter, D. N., & Haxby, E. (2007). Clinical risk management in anaesthesia. Continuing Education in Anaesthesia Critical Care &Amp; Pain, 7(2), 66. https://doi.org/10.1093/bjaceaccp/mkm010
- Stones J, Yates D. Clinical risk assessment tools in anaesthesia. BJA Educ. 2019 Feb;19(2):47-53. doi: 10.1016/j.bjae.2018.09.009. Epub 2018 Dec 14. PMID: 33456869; PMCID: PMC7807823.
- World Health Organization. Patient Safety Incident Reporting and Learning Systems (2021).
- Royal College of Anaesthetists. NAP 6: Peri-operative Anaphylaxis Main Report. 2018.
- NHS Improvement. Guide to Managing Patient Safety Risks and Incidents (PSIRF toolkit) 2022.
- South African Department of Health. National Guideline for Patient Safety Incident Reporting & Learning Version 2, 2022
- .Australian Commission on Safety and Quality in Health Care. Root Cause Analysis Clinical Incident Investigation Manual (3rd ed.) 2023.
Summaries:
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