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• 05 December 2007

Serious and Sentinel Event Reviews at C&C DHB

The following comments may be attributed to Chief Medical Officer, Dr Geoff Robinson:

“Serious and sentinel events that result in patient harm are always a tragedy and profoundly impact on patients and their families, and on staff who do their very best to care for them.

“We acknowledge the impact of these tragedies and unreservedly apologise for the devastating distress to the patients and their families involved in these events.

“Patient safety is of paramount importance in all that we do.

“Therefore anything that threatens that is the cause of profound regret to everyone associated with this District Health Board.

“These cases were identified as serious or sentinel and requiring review. The 23 cases were out of the approximately 86,000 inpatient cases during this two year period. While each of the cases is unfortunate, and we would in no way wish to detract from the seriousness of them, the overwhelming majority of patients who use our services receive outstanding care with excellent outcomes.

“The aim of carrying out reviews of these adverse events is to consider and adopt changes to ensure greater responsiveness to patients’ needs, and to make changes as necessary to improve systems that underpin the provision of care.

“In order for staff to have the confidence and reassurance to openly discuss cases, and for families to receive appropriate support, this process was developed as one of open disclosure, not public disclosure.

“C&C DHB actively encourages staff to take part in the reporting and quality improvement review process and to be open about the circumstances of each case so we can consider all concerns and act accordingly. The process is an essential part of building up a safe system for all our community.

“It is a national and international reality of medicine that sometimes things do go wrong – and even tragically wrong.

“We have carried out significant reviews of our hospital processes and clinical practice, and have made a great many improvements in the time since these events occurred. Some particular examples include:

• Establishment of the Medical High Dependency Bay – four-bed, high dependency area within the Medical Ward that provides a ‘step-up’ facility for patients who are seriously unwell.
• Increased FTEs by four advanced medical trainees within the general medical service.
• Increased SMO FTEs in the Emergency Department
• The introduction of a radiology imaging system (PACS), which provides clinicians with greatly improved access to digital patient images.

“These changes have, and will continue to, substantially increase confidence in the way we currently, and in future will, respond to patients’ needs.

“Our determination to ensure safe, high quality, continuous and responsive patient care is constant and all our staff are committed to continuously improving these systems and procedures.

“We want to assure the community that we have taken significant steps to address the concerns raised immediately after each of these events, and in the time since they occurred.

“Our top priority has always been the safety and appropriate care of our patients and we will continue to provide the very best services we can.”

Please see below for information about significant changes we have made since these events occurred:

A number of steps have been, and are being, taken to address issues arising from these events and from quality assurance processes generally. These include:

• Establishment of the Medical High Dependency Bay – four-bed, high dependency area within the Medical Ward that provides a ‘step-up’ facility for patients who are seriously unwell. A multi-disciplinary team, including a high nurse-to-patient ratio (1:2), ensure patients are given the appropriate level of care.
• The introduction of a radiology imaging system (PACS), which provides clinicians with greatly improved access to digital patient images. The next phase will include electronic signoff of radiology and laboratory tests, meaning alerts will be in place to show if a report has not been reviewed.
• Increased clinical staffing (up from 385 doctors in 2002, to 476 in 2006).
• Increasing the number of beds in the Intensive Care Unit
• Increasing the number of senior doctors in the Emergency Department from three to eight.
• Investing in a series of communications skills workshops for staff.
• Improving the documenting process to support the clear relaying of instructions and observations between medical staff.
• Setting up a regular audit system to ensure that all deaths reported to the Coroner are treated as Reportable Events.
• Reviewing our serious event policy to ensure family are given sympathetic, respectful responses, with prompt and reliable information, after the unexpected injury or death of a family member.
• Implementing a new care planning system that focuses on individual patients and streamlines the process of patient admission through to discharge.
• Implementing a new comprehensive system for electronically recording a patient’s health record. Once implemented, this will enable electronic ‘sign-off’ of clinical test results by the responsible medical staff.
• Purchasing new equipment, including surgical utensils;

Particular Issues:

Co-ordination/Handover:

• Developing a C&C DHB-wide Medical Handover policy, which will include reference to relevant guidelines and will set out the principles of medical handover and include a checklist of procedures to be followed.
• Increased FTEs by four advanced medical trainees within the general medical service and changes rosters so that, except on rare occasions, the admitting registrar is available at the post acute ward round.

Smoking:

• Nicotine Replacement Therapy (NRT) now available as a stock item on all wards. Guidelines disseminated to staff to ensure that early action is taken to provide this as an option to nicotine addicted patients.
• New policy regarding the management of nicotine addicted patients, outlining that it is a significant health problem that requires assessment, care planning and treatment over a period of time unlikely to be confined to a hospital admission. Policy will include practical guidance on how to manage patients who will continue to smoke.

Coroner:

• Multiple prompts now on checklists for medical and nursing staff to consider whether cases should be reported to the Coroner and/or as a Reportable Event.
• Continuing to notify the Coroner of internal reviews of death and providing the Coroner with information relating to those reviews.

Caring for the Physiologically Unstable Patient:

• Ensuring staff are aware of the criteria and encouraged to put out a Medical Emergency Team (MET) call. Education has been provided to nursing staff regarding the criteria and the importance of using the MET team.
• Work underway to roll out a version of the Early Warning Score (EWS) across the DHB. Plan to pilot it within the medical wards.
• Intensive Care Unit outreach nursing service

Scope of Professional Practice and Staffing:

• Identification of areas where Enrolled Nurses (ENs) are able to safely work night shifts within their scope of practice and endorsing a policy exemption for those areas. Working through an appropriate HR process with ENs who have routinely worked night shifts to support them to remain in our workforce.
• Re-emphasised the scopes of practice to all nursing staff and the direction and delegation model which includes the responsibilities of RNs, ENs and Unregulated Health Care Workers. EN’s must always have an identified RN responsible for supervising a patient’s care.
• A focus on direction and delegation, and the implementation of a staff mix. A focused education package is being delivered to support this.

Review of Deaths:

• Redesign of the checklists staff are required to use when a patient dies and providing more specific information such as where the record of death form is to be sent and clarifying the lines of responsibility for transferring information.

Informing Families:

• Developing an Open Disclosure strategy in line with the HDC direction to DHBs. Will be implemented alongside a focused training programme for clinicians.

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