A patient safety alert has been issued by NHS England on the risk of using vacuum and suction drains when not clinically indicated. The alert has been issued for action to be taken by all acute hospitals in England where surgery is performed.
The patient safety alert has been issued following the report of a serious incident to the National Reporting and Learning System (NRLS) when a vacuum drain, in this case a RedivacTM drain, was placed after spinal surgery with the intention that no suction be applied. However, staff were not made aware of the planned management of the drain and, acting in accordance with what would normally be required if the vacuum effect in a RedivacTM bottle had decreased, changed the bottle to one that was vacuumed. The drain rapidly filled with blood-stained fluid, and the patient deteriorated and later died. It is likely that the fluid drained was cerebrospinal fluid (CSF).
Two further almost identical incidents had been reported to the NRLS previously; these cases also relate to patients with a CSF leak following spinal surgery but they resulted in no harm to the patient.
Dr Mike Durkin, National Director of Patient Safety, NHS England, said: “This is now the tenth alert we have issued using NHS England’s National Patient Safety Alerting System since December last year. Patient safety alerts can cover all aspects of healthcare and are a crucial part of our work to rapidly alert NHS providers to risks and provide guidance on preventing potential incidents that may lead to harm or death. Incidents are identified using our reporting system to spot emerging patterns at a national level, so that appropriate guidance can be developed and issued to protect patients from harm.”