Patient safety
Mental health only Not a surgical unit
Not in the desired format
Wanted paying for the information as not in desired format
Would not provide under Section 12 of the act No direct email
No response (to date) Table 1
l The anaesthetist generally took responsibility for choosing how the airway device was fixed, however, it was unlikely that they would secure the device.
l Communications within the environment was mixed and practitioners did not always feel they received two-way communication following an incident or if new initiatives were being implemented into the department.
l Culture often prevented professionals speaking up and speaking out when there were incidents about to occur or if new initiatives were not right for the environment.
l There is still a culture of hierarchy within the environment which can prevent individuals from feeling able to share their ideas.
l Most delegates felt they should have a say in change processes but didn’t feel that they did. Changes happen without collaboration with those people who are going to be using the equipment or undertaking the new processes.
l Most people who joined the focus groups used tapes and ties to secure the airway. Does this amount to standardisation?
l There was little understanding about the infection risks associated with the use of tapes. There was greater understanding about the possibility of facial harm when using ties, tapes, and Elastoplast.
It should also be noted that the National Infection Prevention and Control Manual, Chapter one, Standard Infection Control Precautions (SICPs), states that care equipment can be easily contaminated with blood and other
9
10 3
8 1
12 33 Total responses to the FOI questions
Damage to a patient’s skin when removing the surgical tape used to hold the airway device in place.
Skin damage i.e. pressure sores because of using cotton ties to secure the airway
Death of, or harm to a patient because of inadvertent airway adjunct movement (displacement) or extubation while maintaining patient comfort.
Death or cardiac arrests of patient due to undetected oesophageal intubation Hospital acquired infection because of using tapes that are non-sterile.
Table 2 bodily fluids and infectious agents.2 They classify
care equipment as either: l Single use – equipment which is used once on a single patient then discarded. Must never be reused even on the same patient.
l Single patient use – equipment which can be reused on the same patient.
l Reusable invasive equipment – used once then decontaminated e.g. surgical instruments.
l Reuseable non-invasive equipment (often referred to as communal equipment) – reused on more than one patient following decontamination e.g. commode, patient transfer trolley
Multi-patient rolls of tape are, by definition, classified as ‘non-invasive re-usable equipment’, which by reason of the SICPs above, must be decontaminated to adhere to the National Infection Control Standards. This is clearly not happening as rolls of tape, by their structure cannot be decontaminated. The final element of the triangle of information gathering was through Freedom of Information (FOI) requests to UK NHS Foundation Trusts. The information requested was for the period between the 1 January 2020 to 31 December 2023. Responses from FOI requests to NHS
England Foundation Trusts have shown that a substantial number of Trusts have experienced inadequate patient outcomes because of poor airway management. It has also highlighted that many Trusts do not report the incidents of patient harm. Sometimes this is due to the normalisation of the process and that the incidents are so ‘small’ it is not felt necessary to report them. The FOI requests were designed to define how patient safety is delineated around securing an airway device and how standardisation can be improved to ensure the reduction of current incidents of failure and infection to patients. One Trust noted in their feedback, that many
professionals involved in the management of airway did not want to change their
practices and therefore the trials were difficult to incorporate into everyday processes. Disappointingly, we also saw several Trusts refuse to provide the information and request payment for the FOI. Requests were sent to 148 Foundation Trusts -
the responses are shown in Table 1&2 (above). Five hospitals were unable to provide the information in the format requested but responded as follows: Hospital 1: 69 in total but no breakdown Hospital 2: 17 in total – 5 back of neck and 12 mouth
Hospital 3: 44 in total under the category of airway management. No breakdown
Hospital 4: Five incidents in total under airway and respiratory problems and intubation problems
Hospital 5: 81 incidents in total, 1 x severe harm; 10 x moderate harm and 71 low harm Of the 59 incidents of skin damage there was one incident of severe harm
Complex construct of a safety culture Throughout the findings of the report, we mention a safety culture, which is a complex construct culture as it is characterised by intricate and multifaceted systems of beliefs, practices, social structures and technologies.3 Such cultures typically emerge in groups that have developed significant specialisations and interconnectedness within their ideological frameworks i.e. around patient safety. Within the report, the complex construct was intended as a generalisation and should not be interpreted as applying to specific cases or individual circumstances.
Latest practices and innovations There are many articles that provide valuable insights into the latest practices and innovations in airway device securement, offering guidance for improving patient outcomes in various clinical settings. However, while providing insight into the advancements in airway management, including video laryngeal masks and
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