Table 3 Cohort 2017: summary outcomes (total 330 of which 22 errors)
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Code theme E = error (numbers in italics) T = threats or concerns | Description |
|---|---|
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Error for infection-relating to staff E = 8 T = 44 |
Errors • Nurse removes clips wearing gloves but bin not working so touches with her gloved hand and then checked patient wound (× 2). • Consultant on the phone in personal protective equipment (PPE) leaves isolation room still wearing PPE (× 2). • Operating department practitioner started an incident investigation for non-sterile equipment in theatre (× 2). • Patient had diarrhoea for 3 days and no stool sample taken. • Failure to gown up properly in an MRSA area—infection control told. Other examples of threat concerns Not hand washing • Doctor did not wash hands before entering the bed space and examining the patient. • Ward round no one washed hands between patients. Practitioners coughing, sneezing • Consultant sneezes into hands and proceeds to touch iphone, obs chart and patient’s bedside. No equipment to support handwashing • No alcohol hand gel in bay areas to wash hands. • Physio equipment blocking access to hand gel—no hand washing. Poor infection control awareness • Theatre staff repeatedly brushing against non-sterile parts of the theatre. |
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Staff related T = 16 |
Stretched Staff • Junior doctor in a hurry left with two pagers when on call. • Registrar taken from ward round but knowledge was vital. • Too many patients on a theatre list. |
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Health and safety T = 4 |
• Sharps bin not secure. • Wet floor in theatre not wiped. |
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Patient notes T = 10 |
• Midwife unable to read doctors writing. • Patient could not be discharged as notes missing. |
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Similar patient names E = 1 T = 4 |
Error • Wrong patient—brought one with the same name. |
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Laterality T = 1 | • Incorrect limb labelling. |
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Privacy, dignity and confidentiality E = 1 T = 45 |
Error • Patient not involved in consultation. All advice and explanations were given to the relative; there were no mental capacity issues. Lack of patient involvement meant no ability to raise concerns. Other examples of threat concerns • Discussing patient in a corridor patient overhears and states ‘that’s me’. • Finally a scrub nurse covers patient but left exposed unnecessarily. • Imaging software prompts for password after user name entered. |
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Computer related T = 24 |
• Had to get x 3 computers to try and access a radiology image. • Ward round delayed as no portable computer. |
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Escalation and patients waiting T = 2 | • Patient no referred quickly from A/E and could not receive care available—cause of delay unknown. |
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Risks from poor practice E = 1 T = 2 |
Error • X-ray showed patient had a bracelet on under her plaster. Other examples of threat concerns • Cast removed and pressure sore apparent. |
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Language T = 10 |
• Mother with no English did not know to prepare child for pain on removal of K-wires. • Deaf patient had to rely on lip reading. |
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Not thinking E = 2 T = 9 |
Error • WHO check list all done from memory (× 2). Other examples of threat concerns • Removal of K-wires form child without checking how many were there. • Junior doctor reads patients S number from memory. • Imaging not consulted before K-wires removed. • Not checking who was in the clinic assumed it was the husband. • Patient in fracture clinic can be with nurses, X-ray etc. and there is no record of where they are. |
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Team issues E = 5 T = 24 |
Errors • White board recording swabs and operation equipment was wiped clear before final count and end of operation. • Trainee junior doctor missed the introductory huddle and WHO theatre check and goes onto conduct procedures despite not knowing the team and what was going on. • Breakdown in communication advanced nurse practitioner in the community had left bandages on too long—poor dialogue between the teams. • WHO checklist not read out and considered in theatre (× 2). Other examples of threat concerns • Team briefing using a structured check list was interrupted by midwives swapping places so neither heard the entire brief. • Poor communication between doctor and nurse, ‘Nurse you sort this out’ what? • Use of jargon in a team juniors did not understand. |
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Environment/design T = 40 |
• Clock incorrect in theatre. • Poor place for discussion and group huddle were interrupted with people walking through. • Fracture clinical no space for people in wheelchairs. • Clinic so hot pregnancy mothers have fainted. • Physiotherapists and plaster technicians share a room—no privacy and plaster equipment a hazard for the patients and physios. |
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Drug related E = 3 T = 4 |
Errors • Patient left on a medicine (Tamsulosin) after a Transurethral Resection of Prostrate when no longer needed. Patient now come in for a cataract operation—error noticed. • Junior Doctor prescribed the wrong dose the pharmacist corrected before administration. • Drugs drawn up and forgotten about the consultant anaesthetist notices and asks the core trainee what it is for and gives the drug—poor communication chatting. Other examples of threat concerns • Cannot read prescription. |
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Recording clinical information and consent T = 5 |
• Foetus scan incorrect. • Consent where anaesthetic risk not mentioned and patient given unclear information about operation risks. |
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Investigation related E = 1 T = 4 |
Error • Radiology error: In this case patient had a ring block for manipulation of a fracture but it was not a fracture. Other examples of threat concerns • Insufficient X-ray view obtained. |
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Equipment related T = 10 |
• Wrong bed type for operation—had to be changed. • Use of a radiator for placing equipment as not enough space or trolleys in the room. |
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Poor professionalism T = 21 |
• Registrar answers a phone inform of patient and walks out no explanation. • Patients notes not in trolley—they were in the wrong slot—took 4/5 staff several minutes to find them—but easy to put back in the right place. • Radiographer and ODP talking and joking over a patient under local anaesthetic. |
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Checking T = 9 |
• Points for patients ID × 3 point check. • Wrong patients imaging results checked but was spotted long chain of repeating numbers… too many digits. • Missing test results. • Difficult to read handwriting. |
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Organisational issues T = 4 |
• Clinic too many doctors today but the other day too few—disorganisation of the clinics. • Multiple copies of a patients notes—they had been duplicated. • Organisation of notes from trolley to desk in outpatient clinic chaotic. • Only one key to medicines cabinet—could not find nurse with key. |
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Distraction T = 18 |
• Lots of background noise while WHO check list being done—not everyone could hear. • Registrar having to leave patient on several occasions to take phone calls. • Consultant writing notes frequently interrupted with questions. • Wrong notes brought to patient room. • Lack of read back different members of the team meet and are not discussing the same patient—different S numbers. • Towards end of surgery lots of different conversations going on at once—staff just focussing on individual tasks this is probably because it has been a long procedure. |