In the ANZCA Bulletin there were two articles which referenced webAIRS data. There was an analysis of over 10,000 incident reports in the webAIRS database and four cases of suspected WBIT were found. Dr Suzi Nou performed a detailed analysis which included a Bowtie diagram of the various hazards, methods of prevention as well as management after the event and learning from these outcomes.

Dr Nicole Sheridan and Professor Victoria Eley of the Obstetric Anaesthesia Special Interest Group published an article Inadvertent spinal administration of tranexamic acid which referenced the Analysis of anaesthesia incidents during caesarean section reported to webAIRS between 2009 and 2022. While there were no webAIRS cases where tranexamic acid had been given intrathecally in the webAIRS database there was a report that desctibed a substitution error that involved tranexamic acid. 

Click on the link below to read the article in the ANZCA Bulletin.

Jaw dislocations are rarely reported in the general population. However, they are not an uncommon complication of general anaesthesia requiring airway manipulation. Eighteen incidents of jaw dislocation were identified in 3497 airway incidents reported to the webAIRS database (0.5 percent of airway incidents). These incidents occurred during anaesthesia for gastroscopy, colonoscopy, laryngeal mask airway (LMA) insertion and with yawning on induction.

To read the full article, please click the link below labelled --- More ---

Infusion devices are programmed with algorithms that accomodate the use of a range of medications and pharmacokinetic models. Users haved the option of selecting the program applicable to the medication to be administered. Inadvertent or unrecognised selection of the incorrect program for the medication to be administered will result in a medication error.

In this article, an incident reported to webAIRS describes a patient in their 60s with a history of ischaemic heart disease (IHD), presenting for an orthopaedic procedure on the shoulder. 

The medication in the pump software was incorrectly selected by the user as propofol instead of remifentanil.

WebAIRS has received numerous reports of anaesthetic incidents involving throat packs which are commonly used in Australia during dental, maxillofacial, nasal, or upper airway surgery to reduce the risk of airway complications. 

A recognised complication of the use of throat packs is unintended retention. We present a summary of these reports in the December edition of the ASA Australian Anaesthetist.

--- Members of the ASA please log in to the ASA website to view this article ---

The web-based anaesthetic incident reporting system (webAIRS) reached over 10,000 incidents by the end of November 2022. 1,796 reports were coded by the reporter as involving the cardiovascular syustem and nearly 400 of these reports were reported as involving hypotension. We present a summary in an article in the ASA Australian Anaesthetist March 2023.

The Australian and New Zealand Tripartite Anaesthetic Data Committee (ANZTADC) has recently been using modified colour coded Bowtie diagrams to aid in analysing and visually displaying incidents reported to webAIRS, the web-based Australian and New Zealand anaesthetic incident reporting system. Reports of incidents are regularly published in peer-reviewed journals, the ANZCA Bulletin, the ASA Australian Anaesthetist, and the NZSA New Zealand Anaesthesia magazines. In addition, findings are presented at professional meetings, and the modified Bowtie diagram is frequently used.

Three incidents have been reported to webAIRS concerning patients biting through the stem of a flexible Laryngeal Mask (LM) at the time of emergence from anaesthesia while returning to consciousness. On emergence from anaesthesia, patients may become agitated and delirious with the risk of biting down on either an endotracheal tube (ETT), a SAD, or any other object between the teeth. This may cause partial occlusion or complete transection of an airway device, leading to airway obstruction and in some cases negative pressure pulmonary oedema. The literature reports a greater number of such incidents with ETTs than with SADs. However, the serious complication of negative pressure pulmonary oedema after biting down on LMs is described as uncommon, potentially life-threatening, and under-reported.

To read more with references to the above points please follow the link below.

"We cannot fix what we do not know".

Anaesthesia has a long history of advocating for patient safety. Sir Robert Macintosh, a New Zealander based in Britain and the first professor of anaesthesia outside the United States, first drew attention to fundamental failures in anaesthetic practice in the 1940s. Incident reporting is based on learning from adverse events, ranging from near misses to catastrophic patient outcomes. Learning from experience is an essential part of every anaesthetist's training, but individual events may be less informative than information amalgamated from several similar incidents. In addition, the more reported events, the more likely detection of rare incidents becomes.

Anaesthetic colleagues across Australia and New Zealand are encouraged to use all webAIRS functions and report incidents ranging from near misses to major events across all areas of anaesthetic practice. To learn more about the history and the importance of incident reporting please click the link below labelled --- More ---

WebAIRS recently received a report of lingual nerve (LN) palsy associated with a dual lumen supraglottic airway device (DL-SGA). The patient woke with a bilateral lingual nerve neuropraxia, described as numbness in the front half of tongue. There was no motor involvement, with normal speech, tongue movement, and eating. They had not noticed less taste until they were asked.

A Google query to gain general information regarding LN palsy revealed that a well-known Australian singer, songwriter, and actress, Delta Goodrem, had also suffered a similar complication in 2020 and subsequently had to relearn how to both speak and sing. 

A search of the webAIRS database revelaed a total of 16 cases reported in total. To read more about the details of the outcomes, how to prevent and how to manage this complication of anaesthesia of surgery click the link below labelled  --- More --- 

In January 2022 a search of the webAIRS bi-national anaesthetic incident database was conducted, including the search terms “COVID”, “CV-19”, “Masks”, “N95”, “PPE”, “protect”, or “pandemic” over the period from 11/3/20 to 14/1/22, yielding 76 reports. As it is almost two years since the SARS-CoV-2 Virus (COVID) first reached our shores in late January 2020.  While this number is fewer than might be expected, it is only related to the issues facing anaesthetists rather than all of the problems within the healthcare system.

A detailed reported can be read by clicking the link --- More --- below and a Bowtie analysis is planned for a future article.

A Bowtie Analysis has been performed on the incident reports involving Medical Devices and Equipment among the first 8000 incidents reported to webAIRS. This main category of incidents accounted for 959 (12%) of the first 8000 reports in an initial interim analysis. This article follows on from the article in June 2021 but descibes a different main category of anaesthetic incident. In a similar manner the main hazards (risk factors) for these incidents are described as well as how to prevent and manage similar incidents in the future. In the final section the outcomes and learning from these outcomes are descibed.

To read the full article click on the link below labelled   --- More ---

There have been 398 reports in the category for ‘Assessment and Documentations’ (A & D) amongst the first 8,000 incidents reported to webAIRS. In this article we present an overview of how these might be analysed using the Bowtie Diagram Method. Patient factors that might be associated with A & D incidents include higher ASA PS grades, higher BMI, as well as diabetes, cardiovascular, respiratory, airway, renal, liver, and other organ disease. Task factors include complex or emergency surgery and complexity with the delivery of anaesthesia. Caregiver factors can include the skill level and experience of the person making the assessment. System factors include the availability of a pre-anaesthetic assessment clinic, the patient’s ability to attend a clinic, and the scheduling of the case.

The full text of the article describes how these risk factors which are known as hazards in Bowtie terminology can be prevented by trapping these hazards and if an incident (Top Event) does occur then how the Top Event can be managed. Finally, the last column of the diagram depicts the outcomes and learning from these outcomes. 

To read the full article as well as see an image of the Bowtie diagram click the link labelled  --- More ---  

Advisory Notices to Anaesthetists (Advisory Notices) is a new feature designed to publish case reports on the webAIRS website. It is modelled on the aircraft industry "Notice to Airmen"(NOTAM) notifications which alert pilots to any potential safety hazards along a flight route or in a specified location. They can also advise of changes to aeronautical facilities, services or procedures. The Advisory Notices in webAIRS publish reports which have been set as an "Alert" by the original reporter, together with some useful references if available. To view the alerts you must be a webAIRS member and login to webAIRS. To view these notices login and then select "Advisory Notices" from the main menu.

There have been a number of COVID-19 related reports received in April. The issues mentioned have included shortages of PPE or PPE not provided despite adequate hospital stock. Difficulty intubating whilst wearing COVID-19 PPE due to fogging. Lack of equipment or drugs in the negative pressure room. Incorrect disposal of drugs after a COVID-19 intubation in a negative pressure room. A medication error when staff were deployed to an area where they were inexperienced. For more detail please see the Advisory Notices which can be selected from the main menu (requires login). Please note that there is a Incident reporting page specifically for COVID-19 cases.

WebAIRS has received three reports over the last 18 months where Sodium glucose co-transporter 2 inhibitors (SGLT2), also known as Flozins, have led to euglycaemic diabetic ketoacidosis (EuDKA). In the webAIRS cases, the patients presented for emergency surgery and the SGLT2 inhibitors had not been ceased beforehand. Fortunately, all three patients were managed appropriately, and it was possible to mitigate the degree of harm. A summary was published in the ASA Australian Anaesthetist and the NZSA News Magazine in December 2019. To read more about the case reports and management click on the link below.

The webAIRS Case Report Writing Group.

WebAIRS would like to highlight the online publication of the webAIRS data relating to 121 pulmonary aspiration cases within the first 4,000 reports (1). A brief summary of the article with a reference to the original paper was published in the ANZCA Bulletin in December 2019. To read the full Bulletin article follow the link below. There is also a link to the original Anaesthesia and Intensive Care article in the Publications section of the home page.

Dr Martin Culwick, Dr Michal Kluger and the ANZTADC Case Report Writing Group

Distractions in the operating theatre are believed to be one of the many contributing factors that may cause clinical incidents in the perioperative period. While there have been no randomised controlled trials in an operating theatre environment of which the authors are aware, this principle is generally accepted in the community where activities such as texting on mobile phones whilst driving are believed to cause road accidents. In the webAIRS database a search performed on 13 July 2019 revealed 24 reports where the word ‘distraction’ was used in the narrative and an adverse event or a near miss occurred as a result of the distraction. To read the full article click on the link below.

The webAIRS Case Report Writing Group.

A child presented for a dental extraction and was initially allowed to breathe nitrous oxide with oxygen whilst a venous cannula was inserted. The type of cannula inserted had a new feature named ‘Blood Control (BC)’ which is an automatic check valve, designed to stop the flow of blood after the trochar is removed. The cannula is almost identical to another cannula from the same company without the ‘Blood Control’ feature. There were no difficulties noted during the insertion of the cannula but shortly after the injection of propofol during induction there was sudden severe pain in the arm. It was assumed that an intra-arterial injection of propofol had occurred. The induction was completed with sevoflurane and the cannula re-sited. In stage 2 recovery the patient reported a burning pain down the arm (i.e. distally from the injection site towards the hand) when going to sleep. There was no evidence of ischaemic changes following the injection. Even though intravenous propofol in a small vein can also cause pain up the arm, which is sometimes severe, the anaesthetist submitting the report believed that this was an intraarterial injection. Click on More to read the full article

The webAIRS Case Report Writing Group.

WebAIRS has received a recent report concerning look-alike ampoules. The report stated that “A Xylocaine® ampoule was found in one of the block trolleys in the Marcain® section today.” And added “Please remember to verify all drugs before administration and take care when stocking the trolleys and returning unused ampoules.”

Dr Gerard Eames, Dr Martin Culwick for the webAIRS case report writing group.

Shortly after commencing an ENT procedure the surgeon asked that the patient be positioned head up and the operating table rotated 180 degrees. As the table was being repositioned a large leak occurred after contact with the anaesthetic circuit. It was found that the HME filter had broken off. However the broken end of the filter remained in the anaesthetic circuit which made rapid replacement impossible. This required the use of a self-inflating bag to ventilate the patient until the circuit be repaired. Fortunately no harm resulted to the patient.

This incident illustrates several learning points which include the availability of back up equipment, care during the movement of operating tables to ensure that collisions are avoided and the avoidance of awareness when anaesthetic delivery systems fail.

This report will be expanded into a case report which will be submitted for publication.

Heather Reynolds and Martin Culwick

WebAIRS has recently received a report where an anaesthetist was requested to give intravenous Carboprost (15-methyl prostaglandin F2α) for the management of post-partum haemorrhage by the attending obstetrician. The anaesthetist was in the process of checking the dose and method of administration when the obstetrician approached, stated the dose and assured the anaesthetist that the iv route was appropriate. However, it was later found that the recommended route for the drug is intra-muscular, although off label use of the drug by the intra-myometrial route by an obstetrician does have some published evidence, (which is available on the RANZCOG website). An initial literature search revealed a small study published in 1989 where an intravenous infusion has been safely used. However the study included only 27 women and was not randomised, so the evidence for intravenous use is weak. Side effects with the intravenous route do not appear to have been published, but the side effects with the intramuscular route include severe bronchospasm, systemic hypotension and various gastro-intestinal effects. ANZTADC is researching the issue and plans to publish a summary in the New Year. In the meantime please report any similar cases, comments or suggestions using the webAIRS website.

References

1. Granström L1, Ekman G, Ulmsten U. Intravenous infusion of 15 methyl-prostaglandin F2 alpha (Prostinfenem) in women with heavy post-partum hemorrhage. Acta Obstet Gynecol Scand. 1989;68(4):365-7.
2. Harber C, Levy D, Chidambaram S, Macpherson M. Life-threatening bronchospasm after intramuscular carboprost for postpartum haemorrhage. BJOG 2007;114:366–368.
3. Obstetric Anesthesia, Palmer C, D'Angelo R, Paech MJ.
   
   Martin Culwick and ANZTADC Publications Group

At the recent New Zealand Anaesthesia meeting in October 2018 a poster presentation titled ‘Unexpected Airway foreign bodies discovered during anaesthesia’ was presented. The data relating to sixty reports of foreign bodies was extracted from data collected using the webAIRS database. These items included five cases of chewing gum, one case of chewing tobacco, two cases of metal studs worn as jewellery and fifty two cases of various items related to dentition. The latter included dislodged teeth, crowns or bridges and pieces from broken dental plates. Complications included one case where a tooth was found in the right main bronchus and one case where a tooth was identified in the stomach. This serves as a reminder to be aware of the possibility of foreign bodies in the airway and ensure appropriate pre-operative checks are in place to detect risks from these items pre-operatively. Earlier in the year ANZTADC collaborated and created the website for the Airway Incidents in Anaesthesia Audit Project (AAAP) in conjunction with the Airway SIG. Initial results were presented at the ASA NSC in October by Dr Yasmin Endlich. The AAAP data (including denominator data) was collected from April to October 2018 with 12 participating hospitals from Australia and New Zealand. Closely following the methodology of the National Audit Projects of the Royal College of Anaesthetists (UK), the AAAP data is being analysed and a detailed presentation is planned for the 2019 Airway SIG meeting, which will be held immediately prior to the ANZCA ASM in Kuala Lumpur at the end of April 2019. An Audit Report will follow that summarises the information and some of the findings will be submitted for publication in a peer reviewed journal. ANZTADC looks forward to seeing you at the webAIRS scientific presentations in 2019

Dr Martin Culwick

At the recent ASA NSC in October 2018 there were three presentations which were supported by data collected using the webAIRS server. The first was a first glimpse at the Triple A project (Airway Incidents in Anaesthesia Audit – Australia and NZ) by Dr Yasmin Endlich. The AAAP data was collected from the 3rd April 2018 to the 3rd October 2018 with 12 participating hospitals from Australia and New Zealand which also included denominator data. It is intended to closely follow the methodology of the National Audit Projects that have been conducted in the United Kingdom by the Royal College of Anaesthetists. The AAAP data is currently being analysed in depth and a detailed presentation is planned for the Airway SIG meeting which will be held from the 27th to the 28th April, 2019 immediately prior to the ANZCA ASM in Kuala Lumpur from the 29th April to the 3rd May, 2019. This will be followed by an Audit Report summarising the information and it is planned that some of the findings will be submitted for publication in a peer reviewed journal. Also at the ASA NSC there was a session which was titled “We cannot fix what we do not know”. This included “What we have learnt from the webAIRS airway data” by Dr Yasmin Endlich and “The Bowtie Diagram as a method for providing knowledge about critical Incidents” by Dr Martin Culwick. Discussions are underway for a masterclass and presentations for the ASA NSC in Sydney in 2019. It is likely that a webAIRS Masterclass and a webAIRS session with three presentations will be accepted into the program. It is hoped that one of the international invited speakers will take part in the session as well.

Martin Culwick

Nasal oxygen and diathermy in close proximity: another warning about fire risk

Further to the March issue report on ‘High Flow Nasal Oxygen and Fire Risk’ by Keith Greenland, there have been three recent reports to webAIRS.(1) In each of these incidents, supplemental oxygen appears to have contributed to the ignition of either the patient hair, the eyebrows or the theatre drapes. All three webAIRS reports involved oxygen delivered by the nasal route in sedated patients - one via nasal prongs, the other two via high flow nasal oxygen. Fortunately, in each case the fire was rapidly extinguished. The three procedures involved surgery to the head, suggesting that supplemental oxygen collecting beneath the head drape may have been a contributing factor. On each occasion, the source of ignition was diathermy when being used in the close proximity to the open delivery of supplemental oxygen. From the timing and information provided, it appears that alcohol skin preparation was not a factor in these cases of operating theatre fire.

These incidents provide a timely, further reminder of the risks of the use of diathermy in close proximity to open delivery of supplemental oxygen. It is likely that the risk is greatest when high flow oxygen is used. When diathermy is necessary, supplemental oxygen should be temporarily ceased and wet gauzes or sponges should be used to protect flammable areas.

A case report based on these incidents has been accepted for publication in Anaesthesia and Intensive Care.

Martin Culwick and Sarah Walker

Anti-reflux valve failure

An alert in the June ANZCA e-News informed of a V-set malfunction involving the cracking of an anti-reflux valve and subsequent leakage of intravenous infusions. The webAIRS incident report detailed a propofol infusion running into a Go Medical Industries V-set via a faulty white anti-reflux valve resulting in reduced delivery during a TIVA infusion.

Following the e-News article, an analysis of the webAIRS database was undertaken to identify similar cases. A total of nine reports detailed a problem with a V-set or anti-reflux valve.

Martin Culwick and Sarah Walker

Have you logged on to webAIRS lately? If you have, you would have noticed some user-friendly updates to our landing page. This release provides immediate feedback to users on incident numbers, analysis articles and answers to frequently asked questions via prominent links. For users registered as Local Administrators there are extra filters for incident retrieval and review. Feedback has been positive and these additional functions are providing important opportunity for local M&M meetings and hospital reports. If you are yet to familiarise yourself webAIRS, you can do see via www.webAIRS.org. The Demo Incident tab gives the perfect opportunity to see what’s involved in submitting an incident report. For further information please contact anztadc@anzca.edu.au

Sarah Walker

In the coming months, there are several opportunities to learn more about webAIRS and the outcome of analysis from the first 4000 reported incidents. The Australian Society of Anaesthetists (ASA) National Scientific Congress (NSC) is in Perth from October 7-11 includes a session devoted to webAIRS with particular focus on quality improvement activity in the follow up to adverse events. Along with Dr Martin Culwick and Dr Neville Gibbs, Associate Professor Marjorie Stiegler (from the University of North Carolina) will give some northern hemisphere perspectives on outcomes from adverse events. The ASA NSC will also see Dr Culwick conducting webAIRS workshops. These 30-minute tutorials will be invaluable for anyone wanting to refresh their skills or learn how to register and report. At the NZ Anaesthesia Annual Scientific Meeting in Rotorua from November 8-11, Dr Culwick will give insight into the first 4000 incidents reported to webAIRs – the perfect reminder as to why incident reporting and quality improvement is an important and ongoing initiative. Keen to find out more? Visit the webAIRS website or email anztadc@anzca.edu.au

Sarah Walker

An overview of the first 4000 incidents reported to webAIRS has been published in the January 2017 edition of Anaesthesia and Intensive Care. This reporting milestone was achieved in July 2016 and shows that the most common incidents reported were coded as Respiratory, followed by Medication, Cardiovascular, and Medical Device/Equipment. These four main categories accounted for over 70% of the incidents reported. The outcomes data showed that no harm occurred in 70% of the incidents, while 26% and 4%, respectively, resulted in harm or death. Whilst the no harm category accounted for the majority of incidents, it is extremely important to report these low harm incidents. Analysis of them can assist in developing strategies to prevent the less common, serious harm events or deaths. (Ref Gibbs N et al AIC 2017). A further series of articles are planned for this year with themes including awareness, aspiration, airway, anaphylaxis, hypotension and medications. A preview of the anaphylaxis data will be presented at the ANZCA ASM in Brisbane in May 2017. As of 18 January 2017, webAIRS has collected 4580 incident reports from 144 registered sites which represents considerable growth since the milestone of July 2016. If you haven’t already registered with webAIRS, you can do so quickly and easily from the link on the site landing page (webairs.org.au) Frequent reporting is an important component in the process of quality improvement in our practise.

M.Culwick, S.Walker and N.Gibbs.