CASE 48
Incident
• The death soon after arrival at hospital of a young SCUBA diver retrieved following a diving emergency.
• A ‘near-miss’ drug error that could have resulted in a potentially fatal dose of thiopentone being given by one of the PHR team to an 18-month-old child in status epilepticus.
• A complaint from one of the helicopter air crew who found a blood-filled syringe and needle in a rear, side pocket of the aircraft.
• A vital piece of equipment missing from one of the sealed equipment bags causing a clinically significant change in the medical plan.
• Repetitive equipment malfunction involving one of the monitors after it fell from a stretcher during a retrieval mission.
• Ongoing delays in the response for time-critical pre-hospital trauma tasks caused by ‘communication failures’ in the coordination centre.
• A complaint from one of the receiving ICUs regarding both the clinical care given to a patient during retrieval and the behaviour of the PHR team.
Questions
48.1 What processes can be applied to both monitor and manage such incidents and events?
48.2 How can the quality of clinical care and the safety of the service be improved?
Discussion
48.1 Modern pre-hospital and retrieval services are expected to ensure that the right patient receives the right treatment in the right time and is then transported to the right destination via the right transport. There are subsequently a number of opportunities for adverse clinical and operational incidents to occur. These may vary both in terms of severity (potential or actual outcome) and frequency.
Incident monitoring and the management of incidents or adverse events is an important component of overall risk management. However, when compared to an in-hospital clinical unit, risk management and incident monitoring may be more challenging for a pre-hospital and retrieval service for the following reasons:
• The selected patient cohort is generally of high clinical acuity and complexity. Morbidity and mortality may, therefore, be high regardless of any potentially avoidable incidents or events.
• The clinical environments are variable, complex and potentially dangerous to both patient and team.
• The delivery of clinical care frequently occurs across differing healthcare facilities, healthcare sectors, state boundaries and even national borders.
• The PHR team often work in relative clinical isolation.
• The key stakeholders involved in service delivery are broad and may include clinical, political, financial and patient advocacy groups.
Key incident and event monitoring and management tools include:
• Incident and adverse event reporting. Incorporates activities such as:
• Learning from incidents or patterns of incidents occurring regionally and in other jurisdictions.
• Reviewing ‘near misses’ (also referred to as ‘near hits’).
• Managing serious adverse events.
• Maintaining a contemporaneous risk register.
• Monitoring aviation events or medico-legal cases.
• Sentinel event reporting (see below), including:
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