Administrative procedures

Errors have a tendency to compound themselves, so it is worth taking the time to ensure that essential tasks are carried out carefully. Many complaints arise from simple mistakes that could have been easily avoided. The most common administrative failures are:

failure to pass on important information
failure to arrange appointments, investigations or referrals with the appropriate degree of urgency
failure to review the results of investigations
failure to arrange follow-up and monitoring
mislabelling, misfiling and failure to check labels

Follow appropriate systems

Every hospital should have policies and procedures in place for checking medications, identifying the site of an operation, counting swabs and instruments, and so on. Even so, there are numerous incidents, complaints and negligence claims to show that these checks are far from foolproof; if you place too much trust in them, you may easily become complacent and assume that they have been carried out competently.

There are numerous incidents, complaints and negligence claims to show that these checks are far from foolproof

Before carrying out a procedure, always check the patient’s identity and look at the case notes and relevant images to establish the nature and site of the procedure, even if someone else has already prepared or marked the site.
Familiarise yourself with your hospital’s policy on ordering and administering blood products.
Make sure that any specimens and accompanying forms or reports are accurately and fully labelled.
See that all hazardous substances and waste are labelled with appropriate warnings.
Be aware of health and safety legislation as it applies to your day-to-day work, eg, disposal of sharps, etc.

It makes good sense to stop and listen to [patients] if they express concern about an intended procedure or treatment

No-one is perfect, so clinicians will occasionally overlook, forget, or not be aware of crucial information that has an important bearing on a patient’s wellbeing. Patients therefore have an important role to play in the information system. If they are kept well informed and are encouraged to voice their concerns, they can act as a vital failsafe in the information system.

Patients usually know what they’re in hospital for; they know their medical history, they’re usually familiar with their medication, they have their own welfare high on their agendas, and they rarely mistake themselves for another patient. It therefore makes good sense to stop and listen to them if they express concern about an intended procedure or treatment.

Case report: Wrong kidney removed

The following text is an extract from a serious incident report carried out after a healthy kidney was removed from a young girl in a Dublin hospital in 2008. The child, XY, had a poorly performing right kidney, but had been listed for a left nephrectomy. She was admitted to hospital the day before the operation and consent was taken for a left nephrectomy, as listed. The parents apparently queried the site of the operation, but, despite this, the operation proceeded as planned on the left side.

The team investigating the underlying causes of the error reported the following findings:

Consent

“Patient XY, who was having a major procedure, was clerked and consented by an SHO who was not competent to perform the operation, and who obtained consent on the basis of what was written in the notes. This would be normal practice within the department, although the majority of surgeons indicated that the formal radiology report should also be reviewed at this point.

Reviewing images

“... In patient XY’s case the imaging was not reviewed at any stage:

“In clinic at the point of listing for surgery; At the point of clerking and taking consent; On the pre-operative morning ward round; In response to the parents’ queries about the operation side.

“In addition the imaging was not reviewed in theatre prior to positioning XY for the procedure or making the incision, and intra-operatively when the kidney was noted to have a healthy appearance.

“... the way in which the hospital’s consent process is structured makes it unlikely that the person obtaining formal consent will be competent to review x-rays, and neither are the films readily available on the ward. Discussions in clinic are not universally treated as part of the formal consent process and it is not stipulated that radiology should be examined at that point.

“... The investigation revealed that it not uncommon practice to rely on radiology reports as a substitute for the images.”

Marking the operation site

“Patient XY was marked in the theatres reception by the SpR, in the presence of the parents, on the basis of a review of the medical records (but not imaging).

“At the time of the incident, [the hospital] had no formal or universal process to confirm the pre-operative checks that should be made to confirm that the correct patient was having the correct procedure, and on the correct side. It was essentially at the discretion of the general surgeons to formulate their own practice, based on internationally accepted standards.

“... It was noted by more than one consultant that they would expect site marking to be done when the patient was clerked and consented, ie on admission to the ward, normally by an SHO. This would mean that site marking could not be done with reference to radiological imaging, as SHOs are not felt to have the experience and competence to review imaging, and it would not usually be present on the ward.

“... Ward and theatre staff commented that in their experience patients may not be marked until arrival in theatre. It would not be unheard-of for a patient to be marked after they have been anaesthetised and positioned for the procedure.”

Source: Independent Review Report published by the Clinical Indemnity Scheme at www.stateclaims.ie

Adverse incident reporting system

What do you do if something goes wrong, or you have a close call? Do you think about reporting the incident? If not, you should do. All healthcare facilities covered by the Clinical Indemnity Scheme (CIS) are required to report all adverse incidents to the State Claims Agency. You should, therefore, notify the hospital’s Quality and Risk Department or its equivalent as soon as possible after an adverse event.

The CIS defines a reportable incident as “any patient safety incident directly related to service user treatment or care which did or could have resulted in an adverse outcome”.¹²

The CIS uses the information for two purposes:

to improve patient safety by identifying high risk areas of practice;
to prepare for any claims that may arise from the incident.

What do you do if something goes wrong, or you have a close call? Do you think about reporting the incident? If not, you should do

It publishes annual statistics showing the types of incidents reported (see Box 14) and also produces occasional alerts to particular risks (eg, the management of nasogastric feeding tubes) with best practice advice to minimise the risk.

Box 14: Top five clinical incidents reported in 2009

Slips/Trips/Falls (27,607)
Violence/Harrassment/Aggression (9,445)
Medication incident (8,251)
Records/Documentation incident (5,654)
Treatment incident (5,559)

Source: Clinical Indemnity Scheme STARSWeb Statistics 2009. www.stateclaims.ie

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