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Operating room safety

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If you were to send me into the theatre corridor to find a fire extinguisher or a first aid kit, I will be able to find one. I might not know where it is, but I know what to look for because legislation requires that this emergency equipment is sign-posted and there is an internationally agreed standard sign for each. Sadly, the same is not true for the life-saving equipment that could be essential during surgery.

Thankfully, emergency events in the operating theatre are rare but this does have a knock-on effect: the staff in the operating theatre often have little chance to practice the life-saving tasks that involve the quick location of rapid infusers, resuscitation trolleys, malignant hyperthermia boxes and the like. What is needed is a set of emergency signage for the emergency clinical drugs and equipment in the perioperative environment that is standardised and implemented throughout the NHS. With such a system in place all key emergency equipment could be quickly identified and brought into play in a crisis.

Other factors such as high staff turnover, trainee rotation and increasing agency staff levels add to the lack of familiarity with the hospital environment. Any delay in access to life-saving equipment clearly can have a direct impact on patient safety.

In theory, all perioperative staff, whether hospital-based or agency, have received a departmental induction, but a recent survey has shown that anaesthetic department inductions can vary greatly between trusts and do not always include familiarity with both the emergency equipment and the working environment [1].

The requirements are clear from the recent guidelines from the Association of Anaesthetists of Great Britain and Ireland (AAGBI) that ‘equipment and drugs for rarely encountered emergencies must be available and their location must be clearly signed’ [2]. The need for a world-wide system of emergency signage appears self-evident [3]. Amazingly, there is no standardisation of signage throughout the NHS!

A new group has been created to find a solution: S.I.G.N.S. – Safety Initiative Group for National Signage with the specific aim of promoting perioperative excellence, patient safety and timely crisis resource management.

The S.I.G.N.S. team, part of the MATCH (Multidisciplinary Action Training in Crises and Human Factors) project, have undertaken the Herculean task of creating a bank of 13 emergency/urgent care signs, to meet the requirements of ISO regulations. The MATCH lead Annie Hunningher (Barts Health) along with the MATCH Signs Lead Trudie Phillips (Maidstone and Tunbridge Wells NHS Trust), Queenie Lo (Barts and the London School of Anaesthesia) and Bagrat Lalebekyan (QMUL) with the help of Mark Barley who designed the difficult airway trolley sign have taken Perioperative Signs for Safety to the next level.

Queenie Lo told Healthcare Arena how difficult it is to design a sign: ‘we have to follow very strict guidelines to meet the ISO graphics standards with respect to colour, proportions, size and shape. The graphic design of the signs must ensure that not only are they instantly recognisable but there must be immediate comprehension and recognition by staff from different cultural and ethnic backgrounds.’

The team has already drafted a series of designs and embarked on the lengthy process to test and validate these signs to ISO standards so that they can be launched as a national standard for use in all healthcare environments.

The road to approval of this signage must follow a strict protocol. The first stages involve ‘Delphi’ studies of the designs, where panels of experts undertake a cycle of review-and-comment followed by implementation of necessary design changes and a second review. The initial two stages of the preliminary Delphi Study are now nearing completion and the results are being disseminated. The Safe Anaesthesia Liaison Group (SALG) of the Royal College of Anaesthetists were presented with the initial results in January 2015 and gave the project their full endorsement. The Association for Perioperative Practice (AfPP) recently reviewed the results so far and will be in full support of the project. The results to date will also be presented as a poster at the Association of Anaesthetists of Great Britain and Ireland (AAGBI) conference at the Edinburgh ICC, on 23-25 September.

The team are looking to move the project forward to the next phases, which will include further standardised national Delphi studies, judgement and comprehension testing. In addition, the team are keen to create maps for clinical areas where the signs can be inserted to show the exact location of equipment and these can be shared with the multidisciplinary team.

Pentland Medical is delighted to announce their sponsorship of the project and Stewart Munro, Pentland’s Managing Director, welcomed the team’s work as an important contribution to patient safety in perioperative care. Trudie Phillips the MATCH Signs Lead said ‘This is a big step forward for the project, for supporting frontline innovation and for national perioperative safety’ and as Annie Hunningher explained ‘MATCH has developed a number of projects to enhance perioperative patient safety all of which rely on collaboration and setting new standards’ .

As Queenie Lo explained ‘we must not underestimate the importance of clarity, speed of communication and speed of response in emergencies. These new signs are vital visual components to ensuring that there is no delay to time-critical care and that the impact of human factors is minimised.’


If you would like to comment on any of the issues raised by this article, particularly from your own experience or insight, Healthcare-Arena would welcome your views.


  1. Malhotra R. A survey of anaesthetic department inductions: knowledge of emergency equipment amongst trainees [Internet]. Brit J Anaestha. 2012 [cited 2015 Sep 6]. Available from: http://bja.oxfordjournals.org/forum/topic/brjana_el%3B8326
  2. Association of Anaesthetists of Great Britain and Ireland (AAGBI), Hartle A, Anderson E, Bythell V, Gemmell L, Jones H, et al. Checking anaesthetic equipment 2012: association of anaesthetists of Great Britain and Ireland. Anaesthesia. 2012 Jun;67(6):660–8.
  3. Lee S, Dazkir SS, Paik HS, Coskun A. Comprehensibility of universal healthcare symbols for wayfinding in healthcare facilities. Appl Ergon. 2014 Jul;45(4):878–85.


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