When things go very wrong... a hospital on trial

Transcription

1 When things go very wrong.... a hospital on trial Patricia Snell and team Understand Objectives How things can go wrong The importance of acting on information Where human error might move to Organisation and individual culpability negligence Guy s and St Thomas NHS Foundation Trust DAC Beechcroft University College Hospital, London ISQua Edinburgh, October 2013 Our case today... Uses real professionals Doctor, pharmacist and nurse Beachcroft solicitor who is well known to our hospital and many other UK hospitals Judge Fictitious, but based on events that are very real The players Narrator - Alice Oborne The doctor - Mark Kinirons The pharmacist - Paul Tunstell The nurse - Eamon Sullivan The hospital - Adrian Hopper The prosecuter - Louise Wiltshire The judge - Corinne Slingo We start... We start... Mrs A Young mother of 4 children < 10 years old Runs her own design business Husband is freelance journalist, specialising in medical misadventure for tabloids Setting Acute teaching hospital, part of an Academic Health Sciences Centre General ward Problems Mrs A has been admitted for a routine operation She has a known allergy to penicillin Anaphylaxis years ago Saved by London Ambulance Service Admission to our Emergency Department Developed a non life-threatening infection Working diagnosis: pseudomonal septicaemia Solution Call the experts: Infectious Diseases team 1

2 5.15 pm The timeline Seen by the Infectious Diseases team New prescription not stock on ward Nurse was asked to give 1 st dose immediately 5.40 pm Prescription sent to pharmacy, after closing time 6.00 pm Prescription and drugs sent back to ward 6.15 pm The timeline Injection was prepared by nurse Administered to Mrs A Mrs A goes in to anaphylactic shock. Emergency call is sent 6.20 pm Resuscitation team arrive 6.45 pm Mrs A declared dead Internal investigation Mrs A - despite known anaphylaxis, was Prescribed, dispensed and administered a medicine (piperacillin with tazobactam or Tazocin ) that contained a penicillin Policies and Procedures had not always been followed Delayed Pre - Inquest Husband was admitted to hospital because of mental state Children were looked after by grandparents Husband recovering, but still on medication Wife s business in difficulty because of economic climate and she was the lead designer There had been previous similar incidents Case was referred to Crown Prosecution Service Post Mortem Histopathologist report found: Acute hypersensitivity reaction Prescribed penicillin the likely cause Previous medical history Timeline Charge Criminal The Court Trust Corporate Manslaughter Doctor Gross Negligence Manslaughter Pharmacist Gross Negligence Manslaughter Nurse Gross Negligence Manslaughter 2

3 Guy s and St Thomas NHS The Court The process we will follow Explore the issues it will feel like prosecution to our professionals! There is no dispute concerning the facts Prosecution will sum up Judge will advise the jury on legal issues YOU... will be the jury Our judge will pass a sentence and comment on the learning from incidents like this Dr Mark Kinirons Consultant in Infectious Diseases Prescribed piperacillin with tazobactam, Tazocin 3

4 The Hospital Allergy Procedure Staff Guide to Safe Prescribing Paul Tunstell Principal Pharmacist Prescription Front with allergy documented inside Pictures of props where supply has signature annotation Policy / procedure Medicines policy Allergy policy The prescription chart Prescribed piperacillin with tazobactam, Tazocin 4

5 Guy s and St Thomas NHS The Hospital Allergy Procedure Staff Guide to Safe Prescribing Eamon Sullivan Matron at time of incident Nurse s Entry in the Clinical Record Prescribed piperacillin with tazobactam, Tazocin 5

6 Staff Guide to Safe Prescribing The Hospital Allergy Procedure Adrian Hopper Chief Operating Officer 6

7 Previous incidents Trust allergy policy excerpt Eileen Oliver Surgical patient needing admission to ICU Presentation at meeting open to all staff Other no-harm green incidents Learning + Actions from these incidents Previous message shown on all hospital computers Orange allergy stickers on all inpatient charts Put on by the person who first starts the medication chart PENICILLIN ALLERGIC Penicillin type drugs include: co-amoxiclav (Augmentin), meropenem, Tazocin We are what we repeatedly do. Excellence, then, is not an act but a habit. Separate storage of penicillins Aristotle, BC 7

8 Still testing changes New prescription chart Hand held patient allergy record Warnings through electronic drug cabinets And evaluating these The best doctors Even the sometimes best doctors make the can worst make mistakes the worst mistakes Alan Milburn Alan Milburn visiting Guy s Hospital We are what we repeatedly do. Excellence, then, is not an act but a habit. Aristotle, BC 8