Safety recommendation
It is recommended that the Association of Anaesthetists reviews the dissemination and implementation of its ‘Quick reference handbook’ on managing adverse events during anaesthesia.
Response:
We took this opportunity to highlight to our members that rehearsal of crisis management in unusual locations, such as MRI suites or other remote locations, is essential.
We updated the implementation webpage for the QRH and included a reminder in our e-newsletter to highlight this. We state clearly that QRHs should be available in remote locations where anaesthesia takes place (either permanently stowed there or carried there in a ‘grab bag’ when anaesthesia is taking place).
We also now state specifically that regular multi-disciplinary practice of crisis management should take place and should include special focus on an any location-specific limitations or impediments that exist.
We took the opportunity to reconfirm that the clinical content of the QRH, i.e. the specific instruction provided, is applicable to all locations.
We also reviewed the applicability of the QRH to remote locations such as MRI suites. We concluded that the contents of the QRH, i.e. the instructions contained within it, were equally correct in a remote location as in a theatre complex or anywhere else.
We were reassured that the QRH fulfilled one of our key design aims, that it should be universally applicable without modification, enabling it to be identical in all locations for familiarity in an emergency.
We were reassured that your investigation did not identify any deficits in the QRH. Its instructions on managing the critical incident that ensued would have been the same regardless of location.
However, consideration of HSIB’s recommendation did lead us to conclude that it is the rehearsal of crisis management in unusual locations that requires addressing and this gave us an opportunity to re-emphasise this.
Mutli-disciplinary practice of crisis management is very important but has often struggled to find provision in the pressured frontline of routine clinical work. However, there is increasing impetus from many quarters for organisations to regard it as integral to and indivisible from clinical care.
We also strengthened the wording on our website around implementation of the QRH and to issue a reminder to all members via our e-newsletter.
Changes to the QRH implementation page (https://anaesthetists.org/Home/Resources-publications/Safety-alerts/Anaesthesia-emergencies/Quick-Reference-Handbook-QRH/Implementing)
Point 2 amended:
- The QRH should be immediately available in all locations where anaesthesia takes place; this may mean one copy per anaesthetic machine or one copy per theatre.
- Departments should make sure the QRH is available in remote locations, such as CT or MRI suites and emergency departments. If anaesthesia is only occasionally provided in these locations, it may be necessary to take a QRH along each time (for instance with the anaesthetic machine or in a 'grab bag') rather than leaving one there all the time. Be aware it's harder to police QRHs in such locations and they are more likely to disappear
Point 3 amended:
- The QRH should ideally be displayed in a wall mounted holder, marked clearly with a sign as the location for the QRH. You can download a ready-made template sign for the QRH holder
An additional bullet in point 8:
- In remote locations, regular multi-disciplinary practice of crisis management should take place and should include special focus on an any location-specific limitations or impediments that exist
This reminder to be published in a forthcoming e-newsletter:
“Remember, if you have not already done so, please update your Quick Reference Handbook to the latest version https://anaesthetists.org/Home/Resources-publications/Safety-alerts/Anaesthesia-emergencies/Quick-Reference-Handbook.
We have also updated the guidance for implementation. Departments should make sure the QRH is available in remote locations, such as CT or MRI suites and emergency departments.
If anaesthesia is only occasionally provided in these locations, it may be necessary to take a QRH along each time (for instance with the anaesthetic machine or in a 'grab bag') rather than leaving one there all the time.
In remote locations, regular multi-disciplinary practice of crisis management should take place and should include special focus on an any location-specific limitations or impediments that exist.
Response received on 9 March 2021.