National Patient Safety Day 2020
The 4th National Annual Patient Safety in Anaesthesiology Conference took place, virtually, on Friday, November 13th. One hundred and eighty attendees heard excellent and expert presentations from: Dr. Dorothy Breen: Rescuing the Acutely Deteriorating Patient; Dr. Amy Donnelly: Opioids for Acute Pain in Ireland; Dr. Emma Cunningham: Postoperative Cognitive Events in the Older Patient; Prof. Andrew Smith: The Helsinki Declaration on Patient Safety in Anaesthesiology; Dr. John Fitzsimons: Shared Learning; and Dr. Stephen Drage: Learning from the HSIB Maternity Investigation Program. The KP Moore Medal also attracted substantial attention, with 95 abstracts submitted prior to the event. • The Medal was awarded to Dr. Michael Ma for his presentation Anaesthetic Education in Medication Safety – The Use of Simulation Debrief to Improve Standards of Care. • Dr. Bryan Reidy won the prize for the best podcast - A Storm Approaches - Preparing for a Pandemic. Congratulations to them both. And thank you to all of the trainees who submitted such excellent work. All of the podcasts can be accessed on the College website at http://www.anaesthesia.ie/podcasts
Safety Notice
The Irish Medication Safety Network issued a notice earlier this year in relation to the accidental intrathecal infusion of propofol through a lumbar drain. [Burbridge M, Jaffe R. Accidental Injection of Propofol into a Lumbar Drain. Journal of Neurosurgical Anesthesiology: May 22, 2020. doi: 10.1097/ANA.0000000000000693]. Although the patient came to no harm, subsequent correspondents specified the need to take care with catheters inserted into the subarachnoid space where ISO 80369-6 Compliant Neuro Connectors have not been utilised. They note that not all medications inadvertently administered intrathecally have such a benign outcome, referencing the particular case of tranexamic acid which carries a 50% mortality rate. See Patel S, Robertson B, McConachie I. Catastrophic drug errors involving tranexamic acid administered during spinal anaesthesia. Anaesthesia 2019;74(7):904-14.