Incident 1 (Omission of anticoagulation)
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Causal influences identified
Lack of prompt on EPR* to restart anticoagulation.
Inability to review all medications on one screen in EPR
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Causal influences identified
Failure to seek surgical advice over complex post-surgical effusion
due to excessive workload and inadequate supervision of junior
medical staff.
(Culture, Environment, Organisation/System, People)
Major delays in decision making whilst anticoagulation was suspended
due to weak systems for making, recording & and reviewing
treatment plans. (Environment, Organisation/System, Task)
Inappropriate test (CTPA instead of CXR) ordered to evaluate chest
drain, leading to 4 day delay in restarting anticoagulation due
to lack of appropriate supervision of junior staff and absence
of systems for regular review of patient status and plans (Tools,
Organisation/System, People)
Failure to restart anticoagulation after procedure due to EPR
issues as noted by internal team and unclear responsibility for
post-procedure care. (Tools, Organisation/System, Culture)
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Recommendations made
Omit rather than suspend doses of anticoagulation for patients
undergoing a procedure, if date of procedure is unknown.
Addition of an EPR function to allow prescribed medication to be
viewed by category.
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Recommendations made
Review interdisciplinary working between resp. medicine and thoracic
surgery; develop better referral protocols/guidelines
Overhaul ward round & handover procedures on resp. medicine to
improve supervision, reduce delays and clarify plans
Revise EPR prescribing screens to allow view of all medication, permit
a SUSPEND function with regular PROMPTS to restart medication
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Incident 2 (Administrative error in reporting)
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Causal influences identified
Staff factors: Inappropriate assumption of authority to change
reporting process; no situational awareness of impact of decision.
Organisation: Lack of governance structure, policies, SOPs,
audit, quality control or assurance to guide and monitor reporting.
Unreliable general admin systems.
Communication: Inadequate communication from management to
staff and vice-versa
Equipment: no ability to request histopathology tests
electronically
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Causal influences identified
Internal Investigation analysis endorsed, with one major addition:
Appointment of clinical staff to administrative posts without training
in required skills, or appropriate time allocation for management duties
was an important Culture-related permissive factor allowing the Staff,
Organisation and Communication problems to develop.
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Recommendations made
Development of policies and procedures to guide reporting process
Improved management/staff communication and development of quality
assurance processes
Extension of electronic requesting and reporting to include
histopathology
Modification of electronic system to ensure audit of report receipt
and action
Endoscopists to ensure that referring doctor is sent report
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Recommendations made
Internal Investigation recommendations endorsed
Adequate training in administration, management, governance and
quality assurance to be given to Drs with significant administrative
responsibilities
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Incident 3 (Perinatal death)
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Causal influences identified
Inappropriate allocation of high-risk labour to junior midwife
Failure of midwife to appreciate warning signs and call help
Delay in obtaining US scan
Failure by US staff to respond rapidly to bradycardia on US scan
Failure of Obstetric registrar to attend immediately when shown scan
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Causal influences identified
Missed opportunities in ante-natal clinics to highlight IUGR and
re-categorise pregnancy early on
(Culture, Organisation, People)
Lack of clear unit protocols or SOPs for IUGR, GpB Strep and PROM
(Organisation, Task, Tools)
Patient not transferred to specialist unit although no neonatal bed
was available locally, due to communication breakdown or
unclear leadership. (Organisation, Culture, People)
Loss of situational awareness leading to decision to repeat USS scan
when patient had signs of active labour due to lack of
experience or supervision
in midwifery team (Organisation, People)
Communication breakdown between midwifery and obstetric team led to
delay in decision to go to section (Organisation, Culture, People)
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Recommendations made
Meeting with senior Midwives to stress importance of appropriate staff
allocation
Training lecture for midwives on premature labour, bradycardia and
urgent escalation
Training meetings with ultrasound staff around prioritisation of cases
and response to warning signs
Reflection meeting with Registrar around response to emergencies
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Recommendations made
Review cultural and leadership issues in Midwifery unit
Address workforce and experience issues against clinical acuity in
obstetric service
Conduct multidisciplinary review of local antenatal care pathways,
policies and SOPs for IUGR & high risk pregnancies including policies
for escalation of care, against national guidance on best practice
Review of training needs and support for midwives and trainee
obstetric staff.
Review of processes for prioritisation of ultrasound examination of
antenatal patients and for escalation of concerns from USS to labour
ward.
Consider providing USS service at point of care.
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