Checklist & SBAR for Decision Making in Commissioning a



Checklist & SBAR for Decision Making in Commissioning a

Significant Adverse Event Review

|SAER Reporting and Decision Form |

|Date escalated to Executive Sponsors (Board Nurse Director/Medical Director |Any |

|(Operational Division) (OD): | |

|Patient Name: |A |Directorate: |PLANNED |

|CHI Number: |123 |Service: | |

|Incident Date: |Any |Time: |2200 |Speciality: |ORTHOPAEDICS |

|Datix Ref Number: |WEB13099 |Location: |WARD 10 |

|Severity of Harm/ |EXTREME |Organisation: Operational Division |ACUTE SERVICES |

|Consequence Rating: | |/ CHP/ other | |

| |MODERATE | | |

|SBAR (Situation Background Assessment Response) Communication |

|Situation PATIENT IN Dept B REQUIRED TRANSFER TO CORONARY CARE UNIT |

|POST OPERATIVELY DAY I (EVENING) WITH MYOCARDIAL INFARCTION. |

|Background |

|Elective Orthopaedic admission for left total hip arthroplasty. Past medical history of right total hip arthroplasty, ischaemic heart disease, hypertension, angina |

|and insulin controlled diabetes. Attended for preassessment on 9/7/13, preassessment nurse discussed patient with cardiologist and anaesthetist, happy to go ahead |

|with surgery as planned. |

|Assessment B - On admission blood sugar recorded as 9.3 MMOL. |

|C - Post operatively FEWS (Fife Early Warning Score) 3 on return to ward due to low temperature and hypertension, IVI in situ, O2 therapy in situ, PAIN SCORE 6 using |

|pca as required. BM 11.6, Dr informed staff to monitor meantime. BM rechecked at 17:35 noted to be 12.7 MMOLS. Insulin 72 units administered. Frusemide 40MG given as |

|kardex. FEWS 1 at 18:00. 4 hourly BM stable and FEWS 0 overnight. |

|D - FEWS 1 at 0900 hrs, BM 14.2. Dr was asked to review patient as she was quite drowsy and had been unable to give details to staff when dispensing analgesia at |

|06:00. Routine day 1 bloods obtained, results phoned to ward at 11:10, showing potassium 7.3, HB 100. Medical instructions were to observe, stop oxycontin, commence |

|IVI and commence salbutamol nebulisers. Routine mobilisation commenced with ward physio, but was incontinent of urine on route. Vague when in toilet, assistance given|

|back to bed. C/O visual impairment, inability to grip zimmer. Assessed by ward doctor, all observations within normal limits - FEWS 0. BM 14.7 - 38 units of insulin |

|given. Now uncomplaining of visual disturbance and gripping without any issues. Nebulisers given at this point. Asked to catheterise to monitor output. 20:15 hrs, |

|patient settled, BM 7.5 and insulin withheld. O2 saturations low on nasal oxygen therefore commenced on 4 litres via mask. Light diet and fluids tolerated this pm. |

|Patient moved to bay 3 for closer monitoring where an epidural patient was being monitored 1:1 |

|Night staff came on duty at 21:00 hrs and at 21:30, staff found patient agitated, unable to form proper sentences together - patient aware of this. C/O numbness in |

|both arms, although able to move both arms, checked motor responses in both arms - able to move and squeeze both hands. Oxygen saturations on air 65-70%, lying flat |

|in bed. Position adjusted, 5 litres of oxygen via mask - now 93%-FEWS 1. BM 11.3 |

|H@N contacted and asked to review. ECG and FBC, U&E’s, magnesium and calcium levels requested which were carried out by nursing staff. Ward notified at 22:33. |

|Potassium level 6.7 at this time. Patient transferred to Coronary care unit at 03:10 hrs |

| |Yes |No |N/A |

|The event is on the organisation’s list of distinct adverse events that must always be submitted |X | | |

|for review | | | |

|The adverse event has attracted a consequence rating of ‘Major’ or ‘Extreme’ |X | | |

|There has been an unexpected death | |X | |

|There has been significant harm - either physical or emotional |X | | |

| | | | |

|Please state brief detail re nature of harm/injury: | | | |

| | | | |

|PATIENT REQUIRED TRANSFER TO CORONARY CARE UNIT FOR FURTHER MEDICAL INTERVENTION | | | |

| | | | |

|The event required intervention required to save life. |X | | |

|There is a potential wider impact which may result in harm to a significant number of patients | | |X |

|Environmental events that have caused death, significant harm or required intervention to save | | |X |

|life | | | |

|Events that cause significant (major or extreme ) organisational / other impact e.g. | | |X |

|Other events | | |X |

|Advice has been sought from the Employee Director and Head of Occupational Health and Safety. | | |X |

|Record details of all communications. | | | |

|The event requires that an external agency be notified, such as the Health and Safety Executive | | |X |

| |

|Recommendation |

|e.g. Rapid Event Investigation (REI), Falls Rapid Event Investigation (Falls REI), Significant Adverse Event Review SAER), Other |

| |

|xxxxxxxxx TO ADVISE |

| | | |Any |

|Completed By: |Dr X |Date: | |

A significant adverse event relates to NHS X’s list of distinct reportable events and/or all adverse events attracting a consequence score of ‘Major’ or ‘Extreme’.

The rationale to initiate an SAER is based on best practice and focuses on the three priority elements of unexpected death, significant harm (harm includes negative physical and emotional impact to e.g. a patient and family and/or to the organisation) or which may have required intervention to save life.

Distribution Checklist

|Please forward completed SBAR to: |Date |

|Divisional General Manager/CHP General Manager for Review |Any |

| | |

|DGM/GM Please forward completed SBAR to | |

|x |xxxx |

|xx | |

PART 2 – SBAR DECISION

|Executive Director completing: |Date: |

|X |Any |

|Rationale for decision |Yes |No |

|See below | | |

|Does the Executive Sponsor agree with the CHP General Manager/ Divisional General Manager’s recommendations? |NA | |

|Rationale for progressing to SAER |

| |

| |

| |

|Rationale for not progressing to SAER |

| |

|No clear suggestion above that significant clinical harm has been caused due to substandard care |

|More information required – ie, in concise terms, what is thought to have been the issue |

|A local investigation (REI or SBAR – will take advice on which is most appropriate) will be the most useful/appropriate course |

|If there is has been substandard care then an educational/learning approach will be the best course |

| |

|For further action |Yes |No |

|By Directorate / Service | | |

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|Other | | |

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|DISTRIBUTION CHECKLIST |DATE |

|xxxx |xx |

|xx |xx |

| | |

|Date SBAR Part 2 received by Risk Management Team |xx |

|Date Added to Datix Incident Record | |

PART 3 – INITATING SAER

Timeline of Significant Adverse Event

|Timeline |Due Date |Actioned Yes/No |

|Incident Date | | |

|Immediate Checklist Received | | |

|SBAR Report Received | | |

|Decision of SAER Review | | |

|Initial Pre Log Meeting to agree Roles and Responsibilities of Review Team | | |

|Inform Directorate/Service of SAER Decision | | |

|2nd REI Falls Investigation and RCA Methodology to be completed by | | |

|Arrange to meet/liaise with family/carer to agree expectations | | |

|Pre SAER Meeting to discuss Local Investigation and RCA | | |

|Full SAER Review Meeting | | |

|Development of Action Plan by Directorate | | |

Date/s of LOG and SAER Meetings

|Initial LOG Meeting | |

|Pre SAER Meeting | |

|Full Review Meeting –Nominated staff are | |

|required to attend | |

Review Team

|Name |SAER Title |email |

| | | |

| | | |

| | | |

| | | |

DM/GM to Nominate Key Staff to take part in the SAER Review (DM/GM to Please Complete)

Please staff must be released from duties to attend.

|Staff Name |Job Title |email |

| | | |

| | | |

| | | |

DM/GM to Nominate Family/Carer Contact Person (if not Lead Reviewer) (DM/GM to Please Complete)

|Name |Contact Details |

| | |

|DISTRIBUTION CHECKLIST DATE |

|DM/GM to forward SBAR on completion of part 3 to | |

|xxxxxxxxxxxx | |

| |

|Date SBAR Part 3 received by Risk Management Team | |

|Date Added to Datix Incident Record | |

Datix Response

Mrs xxxxxxx

High risk patient, known DM, known cardiac disease, chronic kidney disease, K borderline hyperkalaemic

Risks clearly discussed with the patient.

Patient seen in Preassess by xxxxxxx, who recommended a cardiac review.

Subsequently patient was admitted to AMAU and CCU 2x in June for cardiac failure

Seen by xxxxxxx subsequently and considered fit for surgery

 

Uncomplicated surgery

Seen the morning post op (day 1), noted to be a bit flat, blood were shown patient was hyperkalaemic with high BMs

Commenced on salbutamol inhalers and given insulin...xxxx indicates her BMs improved and her FEWS settled when he left at 1830 (?). No repeat K was taken.

 

Seen by HAN and noted to have a raised troponin and K elevated (although better than in the am).

Transferred to CCU...K still high, renal function returned to baseline. Cardiac event likely.

 

Reflection

 

1) This patient already pretty frail and at risk of cardiac event in view of recent history of heart failure, although deemed fit to proceed by Cardiology

 

2) Patient probably warranted an HDU bed (may be worth suggesting this is added into the pre-op briefing to ask the question if anyone is likely to require an HDU bed)

 

3) Patient should have had U&Es check later that day, however if the FEWS were 0-2 and the K was falling it is likely management would continue along the line of diabetic control and salbutamol meds

 

4) With the initial high K, patient should have had an earlier medical review

 

5) I was not actually aware the patient had been admitted between preassessment and her surgery until after the op.....it may be worth introducing a question at the initial nursing admission of "Have you been admitted or treated in hospital since your preassessment visit". If I had known this fact I would have postponed the surgery, irrespective of the cardiac opinion.

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