Through its review of recorded patient safety events the National Patient Safety Team identified an issue related to pregnancy testing before anaesthesia.
Exposure to both the anaesthetic and the surgical procedure can present risks to mother, pregnancy and foetus and it is generally accepted that elective surgery should be avoided during pregnancy.
The team reviewed an incident where a patient underwent surgery without pre-operative pregnancy checks being performed. The patient was in her first trimester. A further search of the National Reporting and Learning System (NRLS) identified similar reports.
NICE (National Institute for Health and Care Excellence) guidance, ‘Routine preoperative tests for elective surgery’ – NG45, describes the principles, processes to follow, risk discussions, and documentation required ahead of surgery, including a pregnancy check.
The team discussed potential constructive actions to further reduce this risk with SALG (Safe Anaesthesia Liaison Group), who included ‘Pregnancy tests before anaesthesia’ in the ‘Learning Points from Reported Incidents’ section of their Patient Safety Update (1 April 2021 – 30 June 2021). The aim was to promote greater awareness of the risk amongst anaesthetists, as well as the associated guidance.
About our patient safety review and response work
The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.
In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.
You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.
You can also find more case studies providing examples of this work on our case study page.