Safety recommendation
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.
Response:
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.