Patient inappropriately transferred Flashcards
You are an SHO working in a DGH. A patient from another local DGH is transferred for NIV. However, the hospital staff in the transferring DGH forgot to check, and your hospital does not have any NIV machines available for this patient.
How would you approach this situation?
My initial concern would be the patient who has just arrived. This patient is likely to be unwell, given the fact it was determined he requires NIV. Therefore, my response in the first incident would be to go to the patient and perform an A to E assessment to see if there is anything I could add to their care.
Once the patient is stable, I would then find out as much information about the current bed situation as I could. It might be worth reviewing the ward round notes from the patients currently on NIV to see if there are any who are planned to be stepped down off NIV soon, or ringing around other areas in the hospital (ITU, HDU, respiratory HDU) to find out their current situation.
This situation requires senior involvement, both in terms of the seriousness of the issue. Also, any decision to step another patient off NIV would need senior input. I would liaise early with my senior colleagues, most likely the consultant covering the area or a registrar in the first instance. I would explain the situation to them, including any other information I had acquired about the situation.
What else would need to be done afterwards?
A** formal apology **would need to be made to the patient. The event described in this scenario occurred as a result of a breakdown of communication between the two hospitals and could have resulted in harm to the patient.
In addition, a Datix would need to be submitted for this incident or a serious incident if it was deemed that the patient came to harm as a result.
What is Duty of Candour?
Duty of Candour is a legal duty for health care professionals to be open and honest to patients and their relatives when mistakes occur. It applies to an “unintended or unexpected incident” that “could result in, or appears to have resulted in the death of a service user… or severe or moderate harm or prolonged psychological harm to the service user”.
What is the importance of Datix’s?
The Datix system enables an official record of undesirable adverse incidents to be generated. This then enables the incident to be analysed to identify areas for improvement and training needs to prevent such events from occurring in the future.
By keeping a log of such events, it is possible to monitor what events are occurring in the trust, the frequency of such events and any trends.
What is the Serious Incident Framework?
The Serious Incident Framework is a national framework outlining the responsibilities within the NHS when dealing with serious incidents. It defines a serious incident as one that results in unexpected or avoidable death or injury.
The Framework sets out the principles for dealing with such incidents and outlines the management process, including investigation, report writing and action planning.
