https://padlet.com/postgraduate_futures/d9viq9qarydxuq59 96326 — SP3 — 2023 en-us 2023-03-30 05:40:33 UTC 2023-05-28 14:54:07 UTC hello@padlet.com marisalskrzypek https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2580136452 A midwife noticed a higher than usual numbers of obstetric complications associated with one Obstetrician. She was told that there was no point reporting as the Head of Service for Obstetrics was this Obstetrician's husband, and in the past complaints were dismissed. The midwife felt so strongly that she circumvented the HoS and went to the Director of Clinical Services. A formal investigation ensued which resulted in disciplinary action for the Obstetrician and her HoS husband.]]> 2023-05-06 05:06:52 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2580136452 marisalskrzypek https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2580137038 I noticed a breach of confidentiality from someone very high in the organisation, and reported it to Statewide Integrity and Ethics. It was a complicated situation involving an under 18 prisoner, Covid and his family. An investigation was completed by an external agency and I was contacted several weeks later to say "improvements have been made" but they were "unable" to discuss those improvements, and from what I could tell absolutely nothing changed.]]> 2023-05-06 05:09:44 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2580137038 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2587169716 Working in the Pathology laboratory, there have been rare occasions where not all laboratory tests could be performed as the sample had not been appropriately split between different laboratories due to tests being missed and forms not being read nor followed up, leading to re-collection from the patient, which increases risks to patient safety, especially those who are already vulnerable, such as the immunocompromised and cancer patients.  Such an event had to be reported via IIMS+.  This led to comprehensive investigations, analysing root causes, and laboratory managers, including Clinicians, was involved in building effective management systems ensuring such events were mitigated and risks prevented from recurring.  There are now new systems and protocols, as well as LIMS working on tracking the specimens efficiently and building a 'fool-proof' method to avoid such incidents from recurring. JS]]> 2023-05-11 13:06:57 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2587169716 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2589450389 We recently had a new DHR system implemented, and the medications administered via MAR in DHR. MAR is not user friendly in terms of displaying due medications, active medications or Injections on top of the list. A patient who was in high risk of developing DVT had missed her dose of clexane for 10 days consecutively and end up with extensive thrombus on her upper limb. Incident was reported and we have received feedback and there was a medication safety group started to review the system issues of MAR to prevent further occurrence of same errors ]]> 2023-05-13 10:30:14 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2589450389 huasjiang https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2590620865 A trend was noticed in a medical ward in my organisation that there has been more falls during the winter (ish) months. The organisation bought more falls mat alarms for the medical ward for this upcoming winter. Shirley ]]> 2023-05-15 03:35:04 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2590620865 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2590650692 After nurses in the regional ED I worked in reported multiple incidents where mental health patients were not being appropriately cared for especially when on involuntary orders etc. we were granted funding for a mental health nursing allocation to cover all shifts. Unfortunately, a few incidents occurred to allow the change but it has since improved safety and the quality of mental health care in the department greatly. Something often very poorly done in EDs. ]]> 2023-05-15 04:03:07 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2590650692 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2590966447 In a previous role in an ED it was very much encouraged to log incidents as a way of being able to enact change. On analysis there were high numbers of incidents in which staff reported unsafe workloads in the evening. As a result an additional shift was created to increase our numbers in the busy time. All incidents reported in the department were emailed out to the staff, at the time it felt like an overload but on relfection it was helpful in understanding what was going on and the steps management were making in addressing issues.]]> 2023-05-15 08:20:57 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2590966447 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598209510 Incidents occurred before I started working at my current workplace. In the apheresis department of the outpatient cancer unit, patients frequently became critically ill during treatment, often triggering an emergency alarm. IMMS were generated, direct staff interviews were conducted, patient charts were scrutinised, and eventually, measures were taken to ensure that staff with sufficient combined expertise and experience were available. Staffing measures were implemented to increase the number of staff members. In departments with a high degree of specialisation and a small number of staff, the internal details of the situation are often not widely known, and problems are often discovered late or long after the fact. Therefore, having a solid audit system, open communication, and thorough staff training are important. 

]]> 2023-05-20 08:40:00 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598209510 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598618920 Nursing staff gave a child too much medication when it was realised and reported on they had to redo their medication education and checks. Nothing else appeared to happen, no recognition of system problems that contributed, purely blame on the 2 nurses involved.]]> 2023-05-21 04:00:16 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598618920 David_Sutton99 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598629648 Generally speaking, in my experience staff bemoan having to write incident reports. They feel the ims+ system is too difficult and time consuming to use, even though they admit that it is better than the previous system. When a report is made, staff feel that they get inadequate feedback, or that nothing happens as a result of the report, meaning that the staff feel there is no point in filling them out. This is despite the fact that higher harm scores always get reviewed in the monthly morbidity and mortality meeting.]]> 2023-05-21 04:47:53 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598629648 David_Sutton99 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598630571 One incident report I was involved in was in the day only unit. A patient had their vital signs checked and found to be in PACE call criteria for low blood pressure. The attending staff pressed the emergency buzzer which started an alarm in the complex, however the automatic system failed to page the MET team. Patient continued to deteriorate however an anaesthetic nurse heard the alarm sounding as they passed the unit. The outcome for the patient was delayed treatment, however the ims was brought before the mobidity and mortality meeting. The MET call system was fixed so that the buzzer automatically contacted the MET team.]]> 2023-05-21 04:52:43 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2598630571 cascoy80 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2599402081 An investigation of a wrong sided nerve block before an operation led to a series of slips, lapses and latent factors contributing to the event. Implementation of a 'Stop B 4 U block' process helped focus the process and confirm correct sides and initiating a quality improvement process.]]> 2023-05-22 03:45:18 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2599402081 cascoy80 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2599405362 Ongoing audits of the 'Stop B 4 U block' process revealed an unfortunate change in the rate of wrong sided blocks - a lack of follow-up into the ongoing contributing factors with each incident report is frustrating.]]> 2023-05-22 03:48:02 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2599405362 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2601111633 A staff member reported an incident where a patient had deteriorated after having a spinal anaesthetic. After assessing the incident it and discussing with staff, there seemed to be an education gap. As a result a spinal anaesthetic policy was created and education given to all staff on how to manage spinal anaesthetic. As a result staff were less resistive to patients receiving spinal anaesthetic.]]> 2023-05-23 05:06:58 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2601111633 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2601250571 In the critical care setting you frequently work with patient who are delirium for have TBI’s. One shift a patient was aggressive and i have completed an incident report as the staff were attacked, no sustained injuries but also the patient was weight bearing on non WB leg due to his injuries. I also noted my duress alarm did not work and needed to physically call for help and press the ‘staff assist’
 Was contacted after for details of the other peoples names but did not receive any further feedback.

]]> 2023-05-23 06:47:55 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2601250571 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2601264356 A nursing friend told me about her time in theatres. Specifically when patient require and ERCP they are prone with one arm up and the other down by their side. If the patient was intubated the reposition the caused many pressure areas which were reported. In the new plans of this department the table now in pressure area care friendly for this reason.]]> 2023-05-23 06:57:20 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2601264356 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2604758949 I have made many incident reports using the IIMS system, when patients have presented at different Emergency Departments with existing injuries, wounds or pressure sores. There is a section where I provide my email for feedback, but I have never received updates on any of the reports]]> 2023-05-25 11:52:42 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2604758949 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2605693527 2023-05-26 04:24:25 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2605693527 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607025010 I worked in an area that was known for its toxic culture - I tried to instigate a QI program where there was none. The program was designed to identify differences in practice by reviewing charts, notes and processes and once a month information would be fed back to the team via our team meeting. Minutes were taken during this meeting. All information presented was deidentified and I was trying to move away from name, shame and blame to one of open discussion and transparency. One of my presentations focused on documentation - prior to my presentation my manager said “ get on with it and let us know all the things we are doing wrong “. I did challenge her comment stating that I was trying to not only to identify differences in practice but also was delivering a lot of positive feedback. New people starting in the unit had identified that all the senior staff did things so differently and I was trying to address this in a non threatening, non confrontational way. ]]> 2023-05-28 03:33:19 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607025010 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607144635 I had a patient admitted with LLQ pain, ovarian cyst. She weighed roughly 150kg. C/O pain 8/10 around 0930, given 5mg endone, then paracetamol 1g and ibuprofen 400 around 12. Paged O&G on 4 separate no's at least once each. Paged the AH on call, had switch connect to mobile, it went to message bank. Pain still 8/10 w 5 of endone around 1400. I initiated a CRC to which the team did not respond. I initiated a MET. The MET team took one look at the pt and doubled her endone and increased frequency after which her pain was well managed. O&G had not responded until 1515hrs at which time the Reg yelled at me (forgetting she had a pt in the ortho ward). With the support of the MET coordinator, I submitted an IMS. It was declined on grounds this constituted a personal grievance (never heard of this Dr prior to).
Why even bother?]]> 2023-05-28 12:03:24 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607144635 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607144649 I used to work in D&A. Not long after I started there 45 (yes, 45) diazepam tablets went missing from a safe whose combination was kept in a very obvious place ( this was an OTP cilinic, not a ward). There were lot of sketchy things going on in that workplace and when I had previously raised it with the A/NUM, I was told that things are done differently on the wards, get used to it. The missing diaz instigated a full scale investigation of the clinic, dosing practices, S8/S4 storage and handling. Many things were changed for the better and many people who had worked there for many years were very upset. The resulting changes meant that staff safety was improved because compliance with P&P was improved. ]]> 2023-05-28 12:03:28 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607144649 https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607205564 When I was completing my new graduate rotations in a rural MPS I was involved in an incident with a graesby infusion pump. A colleague had completed an IIMS that the morphine and midazolam infusion for a palliative patient had infused in 12 hours rather than 24 hours. The incident was investigated and the issue was not with the set up of the pump but rather a fault with the device and it's design. Shortly after this graesby pumps were removed from service as multiple other organisations and hospitals had similiar issues. I appreciated the feedback and information provided by my manager.]]> 2023-05-28 14:54:07 UTC https://padlet.com/postgraduate_futures/d9viq9qarydxuq59/wish/2607205564