Critical incident reports: Fife & Lothian

NHS Fife

Case Summary Report ID

Medical Event - a patient was helped into a wheelchair by a physiotherapy student when s/he experienced a sudden deterioration. Staff confirmed the patient was DNACPR (Do Not Attempt Cardio-pulmonary Resuscitation) by running to the ward and checking the notes. Procedures were followed and student monitoring continued.

Learning Points - more accurate and confident reporting using the system in place, and reiteration of existing procedure.

FOI 123 Clinical NHS Fife

Procedural Problems - a patient was diagnosed with a hospital acquired infection from an infected site. During investigation, it was found that the procedure for venflon had not been followed and the records were incomplete. Medical notes were inaccurate and contradicted nursing notes.

Learning Points - improve compliance and cleaning.

FOI 1923 HAI NHS Fife

Slip/Trip/Fall - a patient fell after getting out of bed. The injuries didn't appear to be serious, and s/he was immediately seen by a doctor, and nor were the family told. However, the patient deteriorated rapidly, and died whilst awaiting surgery.

Learning Points - next of kin should be informed immediately following falls, and the patient managed appropriately afterwards. Also, the reporting system should be completed soon afterwards to ensure as complete a record of events as is possible.

FOI 1923 Patient Fall NHS Fife Kirkcaldy and Levenmouth CHP

NHS Lothian

Case Summary Report ID

Slip/Trip/Fall - a patient with a history of falls was found on the floor with a head injury.

Learning Points - enforced use of the Falls Policy and discussion of risks in meetings. Ensure good communication on shift and awareness of risks.

NHS Lothian 1

Medical Event - the patient was admitted to hospital with an ulcer on the left heel, but it appears s/he developed other ulcers during the stay in hospital despite apparently being able to turn and move freely on a therapeutic mattress.

Learning Points - pressure ulcers need to be reported even if the patient has pre-existing ones.

NHS Lothian 2

Medical Event - a patient was waiting to go into surgery when s/he went into cardiac arrest and died.

Learning Points - remind anaesthetic staff that there are a number of consultant anaesthetists trained in the use of Transoesophageal echocardiography (TOE) and that their help may have been sought in this circumstance in daytime working hours.

NHS Lothian 3

Slip/Trip/Fall - the patient fell and sustained fractured femur. S/He was know to have dementia but wasn't assessed by the ward to need an escort. Levels of staffing at the weekend meant that an escort wasn't available.

Learning Points - all dementia patients or those who are confused should have an escort.

NHS Lothian 4

Investigation/Diagnosis/Treatment Problems - there was a delay in a cancer diagnosis of over a year, however the case was complicated.

Learning Points - there should be a review of documentation and communication with patients and GPs plus a review of this specific case regarding radiology and pathology decision making.

NHS Lothian 5

Investigation/Diagnosis/Treatment Problems - a patient went for an investigation and during the procedure deteriorated significantly. the procedure was stopped, but the patient later died. There were notes missing from the records that may have alerted the clinician to the dangers of performing the procedure.

Learning Points - ensure staff have up-to-date knowledge and that consultants delegate safety briefings to nursing staff

NHS Lothian 6

Medical Event - harm to a patient.

Learning Points - none.

NHS Lothian 7

Slip/Trip/Fall - a patient tried to move alone and fell. S/he sustained a fracture which wasn't immediately diagnosed.

Learning Points - raise awareness of the risks of falls and appropriate compliance with policy. Discuss in daily safety brief with nurses.

NHS Lothian 8

Other - a patient at home took his/her own life. This person had a history of mental health problems and had been undergoing specialist care, but was due to be discharged.

Learning Points - none.

NHS Lothian 9

Procedural Problems - blood was needed urgently, but the switchboard didn't organise a dedicated emergency porter they should have. Fortunately in this case, another porter was available to help.

Learning Points - correct policy be identified and staff clearly made aware of correct response in this type of situation

NHS Lothian 10

Medical Devices - a patient was using a wheelchair that was not large enough and resulted in pressure sores. There was some miscommunication between the carers and medical team and the report says the GP should have notified nurses sooner to the problem.

Learning Points - upscaled supervision of support workers, and improved training about skin care.

NHS Lothian 11

Slip/Trip/Fall - a member of staff was hurt when s/he was getting down from putting up a ceiling Christmas decoration.

Learning Points - do not put Christmas decorations up. There should always be two people available when using ladders.

NHS Lothian 12

Medical Event - a patient was discovered dead in bed. There were concerns about the combination of medication and alcohol intake.

Learning Points - lowering the threshold for particular blood tests to detect undisclosed alcohol abuse. Earlier disclosure/detection of the alcohol problem may have reduced the risk to the patient.

NHS Lothian 13

Tobacco Related Incident - a patient on oxygen therapy had previously been able to go outside to smoke lit a cigarette in a toilet. This prompted an explosion where the patient died and the ward had to be evacuated.

Learning Points - signs warning of dangers of smoking when having oxygen therapy. There was also consideration of the possibility of nicotine replacement therapy for patients who are unable to leave the ward to alleviate symptoms.

NHS Lothian 14

Other - the death of patient in unknown circumstances.

Learning Points - none.

NHS Lothian 15

Slip/Trip/Fall - a patient had fallen earlier in the day. S/he was immediately assessed and given symptomatic relief. The doctors were paged three times, but because of the bank holiday they were in high demand throughout the hospital. A later scan indicated a neck fracture.

Learning Points - an improvement plan to review the falls risk assessment and care plan in place, pressure mats have been trialled and their purchase has been requested (will be used for patients who're likely to fall) and nursing staff to emphasise urgency for a doctor to come and see a patient.

NHS Lothian 16

Medical Event - a patient death. The ambulance service pre-alerted the hospital.

Learning Points - none.

NHS Lothian 17

Moving/Handling - a patient was being pushed in a wheelchair by another patient, when s/he fell and fractured his/her hip.

Learning Points - none.

NHS Lothian 18

Other - one outpatient had killed another outpatient - they had previously been in a relationship that had recently ended.

Learning Points - none.

NHS Lothian 19

Other - a patient with a history of alcohol abuse died suddenly.

Learning Points - none.

NHS Lothian 20

Moving/Handling - a patient injured his/her knee when being assisted into bath by staff.

Learning Points - the team should be mindful to prompt patients when turning.

NHS Lothian 21

Other - an outpatient was found dead at home.

Learning Points - none.

NHS Lothian 22

Other - an outpatient died.

Learning Points - more frequent medical review of medication for high risk patients. This patient may have benefited from an increased alertness to risk associated with patterns of poor attendance.

NHS Lothian 23

Investigation/Diagnosis/Treatment Problems - a chest drain was placed incorrectly which affected the patient's health.

Learning Points - none.

NHS Lothian 24

Slip/Trip/Fall - a patient was confused and was wandering alone when s/he fell. The patient had a history of dementia.

Learning Points - none.

NHS Lothian 25

Medical Event - a patient recently discharged from hospital represented with a cardiac arrest.

Learning Points - none, but indicates a full investigation into this should be done.

NHS Lothian 26

Investigation/Diagnosis/Treatment Problems - a patient at a high risk of stroke had their anticoagulant drugs stopped. S/he suffered a stroke and died. It's unclear who and why the anticoagulant was stopped.

Learning Points - a discussion with the anti-thrombolytic committee to check guidance.

NHS Lothian 27

Other - a patient with a history moderate alcohol abuse died of a heart attack.

Learning Points - none.

NHS Lothian 28

Slip/Trip/Fall - a patient fell and sustained a serious head injury. New or newly transferred patients can be confused and disorientated by their new surroundings.

Learning Points - none.

NHS Lothian 29

Slip/Trip/Fall - a patient fell and sustained a fracture to the femur.

Learning Points - the ward is testing if there are ways of preventing falls that can be implemented.

NHS Lothian 30

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