Dr Barry Lyons

CAI Patient Safety Director


Earlier this year, the second Irish National Adverse Event Study was published. The purpose of the project was to quantify the prevalence and nature of adverse events in acute Irish hospitals in 2015, and to compare the results with the previously published data from 2009 (INAES-1)1. With the exception of hospital acquired infection, disappointingly there was little difference between the data from 2009 and that acquired in 2015: the percentage of admissions associated with one or more adverse events was unchanged - 14% in 2015 compared with 12.2% in 2009 (p=0.48). Similarly, the prevalence of preventable adverse events was unchanged at 7.4% v 9.1% (p=0.3). Although the INAES studies provide some insight into adverse events in hospitals in Ireland, in general we generate (or publish) regrettably little data about patient safety in this country. The first article in this newsletter provides some preliminary information about critical incidents in anaesthesia. Written in collaboration with the State Claims Agency it outlines those incidents reported to the National Incident Management System (NIMS) in the first 6 months of 2020. One thing that is clear from the data is that medication safety must remain an area of focus and concern for all anaesthesiologists. Also published this year was the UK Healthcare Safety Investigation Branch’s National Learning Report on Never Events2. The HSIB carried out a structured qualitative analysis of Never Events using the Systems Engineering Initiative for Patient Safety (SEIPS), a systems approach that has human factors principles embedded within it. The review identified 17 themes contributing to so-called Never Events, and concluded that the barriers designed to prevent Never Events were neither strong nor systemic. Indeed, what is evident from the analysis is that established barriers to Never Events commonly rely on human behaviour. Safety science would appear to cast doubt as to whether any human process can provide a strong and systemic barrier “as all human action is vulnerable to human error”3. Nonetheless, in the absence of robust and universally implementable technological or structural barriers, human interactions and performance remain an essential part of the safety structure. The focus of this issue of the safety newsletter is mainly on human factors. Dr Jenny Porter considers some of the lessons from especially safety-focussed non-healthcare industries that we have imported into medical training and performance. One element that we need to embrace further is crew resource management, which addresses in-situ hierarchies as well as communication, leadership, and interpersonal skills. The importance of this cannot be overstated – “in the operating room, patient safety is dependent on effective working relationships between all members of the perioperative team”. Dr. Mai O’Sullivan also highlights the importance of human factors (and of simulation training for preparedness for critical events) in her highly personal account of accessing emergency front of neck access in the ED with limited support. Prof. Ellen O’Sullivan discusses the development of the Difficult Airway Society guidelines in response to NAP4, and sets out the need to develop a network of institutional airway leads with a responsibility for, amongst other things, education, inter-speciality co-ordination, and organisational preparedness for critical airway events. The “can’t intubate can’t oxygenate” scenario is a severe test of an anaesthesiologist’s capacity to manage under pressure. However, the stresses that we face routinely are not always of such an acute, patient-facing nature. Often they are insidious and emanate from expectations that we have of ourselves, or through inter-personal interactions, or from institutional or organisational demands. Such stressors can have a significant impact upon our long-term emotional and mental wellbeing. Dr. Tara Feeley reviews some of the work of the “Care Under Pressure” project, a research collaborative that proposes to examine aspects of doctors’ mental ill-health, and how this might impact on both the clinical workforce and patient care. If we were not already aware of the extent of human inter-connectedness, the Covid-19 pandemic has served as an illustration of how events in other parts of the world can have a profound impact on our own social and economic re-engagement. Beyond the pandemic, climate change remains the greatest threat to many of the social and environmental determinants of health – clean air, safe drinking water, sufficient food and secure shelter. Anaesthesia is a contributor to greenhouse gas production, and thus our choices and actions have a global reach. It was heartening to see the importance of this recognised through the recent awarding of the Delaney Medal to Dr. Oscar Duffy for his work on the carbon footprint of inhalational anaesthetic agents in Ireland. Dr. Rebecca Marshall, who was part of the collaborative involved in this project, writes about the things we might do as anaesthesiologists to practice anaesthesia in a more sustainable way. Finally, the CAI annual patient safety conference – NAPSAC 5 – takes place on Friday, November 12th. It is hoped, public health stipulations permitting, that this will be a hybrid event – both in-person, and online for those who wish to attend virtually. The draft programme of what promises to be an interesting and engaging day is set out on the last page.


1. Connolly W, Rafter N, Conroy RM, et al The Irish National Adverse Event Study-2 (INAES-2): longitudinal trends in adverse event rates in the Irish healthcare system. BMJ Quality & Safety 2021;30:547-558. 2. https://cpoc.org.uk/sites/cpoc/files/documents/2021-03/HSIB_Never_Events_-_analysis_of_HSIBs_national_investigations_Report_V09.pdf 3. NHS Improvement. (2018) Never Events policy and framework: revised January 2018. https://improvement.nhs.uk/ documents/2265/Revised_Never_Events_policy_and_framework_FINAL.pdf