Pleural procedural safety in the UK: is everyone's house in order? Reflections from the BTS National Pleural Service Organisational Audit and a national review of patient safety incidents.

Abstract

Introduction: The 2022 British Thoracic Society Pleural Services Organisational Audit highlighted evidence of ongoing risk of harm from pleural procedures. To better understand the underlying causes of these safety concerns we undertook a review of patient safety incidents from the National Reporting and Learning System (NRLS).

Methods: Incident-level patient safety data from NRLS were requested from any level 3, 4 and 5 incidents describing harm resulting from pleural intervention, specifically chest drain insertion or pleural aspiration for pleural effusions (fluid), submitted between 1 April 2018 and 30 March 2022.

Results: 256 incidents were identified. Most of these did not directly relate to a pleural procedure or its concerns and so were excluded. Ultimately, 21 incidents (including 2 deaths) were relevant. 17 involved direct organ puncture, predominantly liver (n= 13). 11 incidents involved seldinger drains, 5 blunt dissection drains and 1 involved both (not specified in 4). In only four incidents was it clearly detailed that an ultrasound-assisted approach had been used. In the remainder, the use of ultrasound was largely not detailed at all, or the approach used was not clear or inappropriate. Most (19/21) events occurred out with respiratory environments.

Discussion: These data raise concerns about pleural intervention for fluid occurring where lack of appropriate ultrasound use may have contributed in a variety of clinical areas. This should be highlighted at a national level by specialty groups and societies. We welcome an upcoming National Confidential Enquiry into Patient Outcome and Death study to help cement our understanding of factors underlying this ongoing risk of harm and to enable definitive action to be taken to reduce this risk.