Country Health SA

Don’t Find A Fault – Find A Remedy

December 18, 2015 by Tim Leeuwenburg 3 Comments

I’ve just been reading the latest Clinical Communique from the Victorian Institute of Forensic Medicine – stoked to see fellow FOAMed enthusiast Gerard Fennessey contribute, along with a reference to a paper written by Casey Parker (BroomeDocs) and myself on the value of FOAMed for rural clinicians. There’s also expert commentary from Ass. Prof Matt Hooper on retrieval services. These clinical communiques are excellent resources and a great source of tacit knowledge sharing. Check them out here

All of which has made me think about the issue of audit in rural practice. It’s very easy to ‘point the bone’ to failings in rural practice. Of course highlighting failings is important – but all too often systems seems geared more towards punishment, rather than gaining a true understanding of causative factors. And this is where audit (part of clinical governance) becomes relevant.

Clinical governance is really important. One of the (many) things I’ve learned from the prehospital environment is how clinical governance is essential to driving quality improvement. At SA Ambulance-MedSTAR (South Australia’s retrieval service), cases were audited every week which has the potential to drive quality improvement. As Hooper says in regard to retrieval services

“clinical governance, audit and educational activities should be multidisciplinary such that referral and receiving teams and the retrieval service are able to share learning outcomes….
…It is only when this occurs that the outcome for individuals disadvantaged by the need for retrieval are improved irrespective of gradients in the level of care available”

The problem of rural audit

Things in rural South Australian hospital are a little different to the finely-honed mechanism of a retrieval service. Many hospitals are staffed by visiting medical officers who work on a ‘fee for service’ basis. Some of the larger ones have salaried medical officers, but most are on a VMO basis – and are hence attend only to see hospital cases – and depart as soon as care is completed. Participation in hospital audit is far down the list compared to the pressures of running their own practice and providing an oncall service to the hospital.

Yet one of the hardest thing that rural doctors do it manage critically ill patients – such work is often required to be done with inadequate equipment and of course is performed relatively infrequently. It’s stressful and of course a potential for mistakes with adverse patient outcomes. Of course the running of the hospital itself and the training of nursing/ancillary staff is the responsibility of Country Health SA. The nursing staff across rural hospitals are, generally, of a good standard – with mandatory training and skills maintenance dictated by Country Health SA. But how about the doctors?

Well, some rural doctors do this sort of work very well indeed. Most are average. Some don’t do so well, understandably deskilled by the relative infrequency of such events and the paucity of equipment I am interested in how to make this better – whether through increasing access to appropriate equipment, training through in situ sim, upskilling opportunities or through reflective practice. The development of appropriate guidelines designed specifically for rural practice is best driven by audit of such cases (what works in a tertiary centre may not work so well in a rural environment- viz many massive transfusion protocols).

“The surviving sedation guidelines 2015 collaborative project is a good example of rural guideline development, taking the best evidence and applying to this environment to assist practice in an inherently high-risk clinical situation. Safe sedation and management of the soiled airway is something we practiced as sim in the RDASA Rural Docs Masterclass”

But here’s the problem – it can be hard to give feedback on such cases to team members. The retrieval service is busy and may not have time to report back. In turn the rural clinicians involved have often gone home or disappeared to clinic. Worse they may not be receptive to feedback unless delivered sensitively. Moreover, such feedback may be confined to patient outcomes, and ignore the nuances of non-technical factors in the management of critical illness. In addition, the feedback may be given to an individual clinician – but there’s not necessarily an opportunity to feedback to the team as a whole.

It’s true that many times the team members train separately – for example, upskilling courses purely for doctors, in-hospital training delivered solely for nurses. This is inevitable when scant heed is paid by organisations to the importance of human factors and the benefits of in situ team training and regular audit.

So – I am increasingly interested in the concept of feedback from all members of the resus team – as part of audit and to help drive quality improvement. Rather than look upon this as ‘finding fault’ it’s more about ‘finding a remedy’. Is this part of the solution?

Debrief – as a routine?

The concept of debrief is not new – it’s almost de rigeur after a critical incident, a cardiac arrest or a significant event (paediatric resus etc).. these are times when emotions may be raw due to the impact of the resuscitation and debrief is seen as a good thing to help individual team members make sense of the events.

But should debrief be routine after any critical illness requiring retrieval? Perhaps not in larger centres – but I think the answer has to be resounding “YES!” for small rural hospitals where managing critical illness is relatively infrequent and there is much scope for learning and improvement.

Such debrief needs to gather input from all team members in a non-judgmental manner, allowing exploration of technical and non-technical aspects as part of a commitment to quality improvement. Allowing time for all members of the team to highlight areas for improvement can generate meaningful and shared objectives for change.

Feedback and debrief can also allow positive reinforcement of practices and behaviours that worked well – rather than debrief descend into nit-picking over trivia, there’s a chance to reflect on what worked well and to praise individuals. The corollary is that causative factors in ‘what didnt work well‘ can be explored and hopefully addressed. This may be problems with communication (most often), with equipment, with clinical skills or knowledge.

There’s no doubt in my mind that the model of private VMO and salaried rural hospital staff doesn’t work well for regular team training nor audit, because such activities are unpaid extras for the VMOs – unless authorised by the hospital. This in turn leads to a disconnect, presenting a wasted opportunity for quality improvement.

“The team that trains together will improve together”

Moreover, there may not be an organisational imperative to seek feedback on such cases. I recall a comedy moment in recent years where one senior Health manager (with overriding responsibilities for one aspect of rural health) assured me that there was “no need for audit of emergency cases; we already get told what to do when the Coroner gives a report”.

So – how to overcome this?

The hot debrief

The hot debrief – immediate post event discussion amongst team members – is a good chance to drive quality improvement once the critically ill patient has left the rural hospital. Advantages are that team members are immediately available and can, if the appropriate culture exists, have a quick group huddle and talk about what went well/what could be improved.

Of course such efforts may be sabotaged if there are other imperatives – more patients to see, a messy resus bay to clean, the chance to grab something to eat….or the fact that patient outcomes are unknown. Hot debrief is a valuable tool, but can omit the ‘big picture’ of events before arrival and after levaing the rural facility.

Routine audit

I’ve been asking various people in Country Health SA for the routine audit of critical patients in rural hospitals for some time….of course it’s invaluable to have the input of the retrieval service (and this often happens).

Rather than wait passively for feedback, I believe that an extra dimension to local quality Improvement can be driven by rural hospitals using a structured tool. Feedback can be given by all members of team, whether lead clinician, nursing team member, volunteer ambulance officers, ancillary staff etc … and gives an opportunity for reflective practice once further information on the case is available

“In sim, we debrief after every case – and yet we don’t after a real emergency”

Encouraging the routine (but of course voluntary) use of feedback forms post a retrieval or resus allows chance to examine both technical and nontechnical aspects of care with a view to driving quality improvement. It requires a culture of openness, honesty and free of fear of retribution. Audit of cases is not a ‘test’ – but an opportunity to drive quality care.

Here’s one I’ve been playing with on KI – RURAL AUDIT & FEEDBACK FORM.

It has received some good feedback from colleagues interstate and I’d be keen for further feedback from readers on how this form could be improved for rural practice.

Practice elsewhere

As stated above, the retrieval service SA (MedSTAR) already do audit of each and every case and do a bloody good job of it. There model is one to aspire to. Similarly many rural anaesthetic practices (interstate at least) have regular audits and teleconferences to discuss interesting cases or ‘near misses’. This is a good thing – although as far as I know there is no involvement of rural hospitals in the National ANZ Airway registry – a wonderful initiative that has really driven change in the practice of emergency department intubation.

Wouldn’t it be awesome to have a robust system of proactive clinical governance, lead by rural clinicians, involving all involved staff – with a view to incremental improvements in quality?

Horse-and-stable-door — *Review of cases only after a clinically significant incident is a case of ‘acting after the horse has bolted’*

Currently, it seems that SA Health has no robust audit of emergency cases in rural hospitals unless there is reporting of a critical incident or a finding from the Coroner. To my naive mind, such audit and reflective practice involving the whole team should be routine and part of our culture. In an ideal world, I’d love it if

rural hospitals routinely audited emergency cases, especially those requiring retrieval or unusual levels of input (equipment staffing etc)
senior clinicians in the receiving facility were able to feedback dispoisition, as well as referring clinicians making it a habit to enquire after every case ‘sent to the big hospital’
it was easier for the busy retrieval service to ‘close the loop’

In addition to clinical feedback, meaningful audit should explore issues with communication, equipment and team dynamics.

Perhaps many of you are already routinely auditing your emergency and resus cases? If so, how are you doing it? Ad hoc? Structured? Multidisciplinary? Involving ambos, ancillary staff, nurses, doctors, admin?

I would be really interested in what is happening elsewhere in Australia – or overseas – for audit of critical care in rural locations, by rural clinicians.

RURAL AUDIT FEEDBACK FORM

References

ANZ Airway Registry – http://airwayregistry.org.au

Couper K & Perkins G (2013) Debriefing after resuscitation Curr Opin Crit Care. 2013 Jun;19(3):188-94. doi: 10.1097/MCC.0b013e32835f58aa. http://www.ncbi.nlm.nih.gov/pubmed/23426138

Fogg T et al (2012) Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia Emergency Medicine Australasia, 2012, Vol.24(6), pp.617-624

Fogg T (2015) et al Airway Registry: Closing The Audit Loop http://airwayregistry.org.au/acem-2104-rnsh-final.pdf

Leeuwenburg T. (2012) Access to difficult airway equipment and training for rural GP-anaesthetists in Australia: results of a 2012 survey Rural and Remote Health 12: 2127. (Online) 2012 Available: http://www.rrh.org.au http://www.rrh.org.au/publishedarticles/article_print_2127.pdf

Leeuwenburg T & Parker C (2015) Free open access medical education can help rural clinicians deliver ‘quality care, out there’ Rural and Remote Health 15: 3185. (Online) 2015 http://www.rrh.org.au/publishedarticles/article_print_3185.pdf

May N (2013) It’s Good to Talk – Debrief in the Emergency Department StEmlyns Blog http://stemlynsblog.org/good-to-talk-debrief-in-the-emergency-department/

Surviving Sedation Guidelines 2015 – see guidelines as a PDF at http://kidocs.org/wp-content/uploads/2015/05/SSG2015v6.pdf – also blogpost via BroomeDocs and podcast here http://content.blubrry.com/prehospitalpodcast/PHARM-2015-05-12-119.mp3

Victorian Institute of Forensic Medicine – Clinical Communiqué – December 14, 2015 Volume 2 Issue 4 December 2015

Safety in Resus – Use the Whiteboard!

December 5, 2015 by Tim Leeuwenburg 2 Comments

There’s no doubt that for the small rural emergency department, a critically unwell patient can quickly overwhelm available resources. Like many small rural hospitals in Australia, there is one doctor on call for emergency presentations, with the ward-based nursing staff (two in out location) responsible for ward care, assessment of outpatient attendances as well as care of patients in the ED. Not surprisingly this can be a big ask…and thankfully extra nursing and medical staff are available if needed (typically the oncall theatre team)

As we ramp up into the tourist season on Kangaroo Island, I’ve been thinking about how we deal with critical patients in our rural ED. Having the appropriate training and equipment is obviously important – as well as an appreciation of resus room feng shui.

A recent retrieval case brought the issue of improved team communication to mind. I wont go into details; suffice it to say that this case required the attention of two doctors, seven nursing staff, one paid paramedic and four volunteer ambulance officers….and subsequent retrieval. The demands of one critically ill patient … plus several other ED attendees … plus ward care can quickly overwhelm local resources, without a robust oncall system.

But no matter how well equipped, how well trained or even how well staffed the ED is, there HAS to be effective communication between members. We did quite well, but on reflection afterwards I felt that it was hard to keep track of who did what and when. This is often the case in a resus team, particularly occasionalists or the ‘flash team’ or individuals who have not trained together.

The traditional and practiced role of a resuscitation team is based on that of team leader, with subsequent role allocation and closed-loop communication between members, all operating with a common goal or ‘shared mental model’. This is the sort of stuff we teach on the ETMcourse, focussing not just on the technical skills of trauma care, but also on the nuances of effective teamwork in trauma.

In recent times I have become a fan of using the whiteboard as ‘glue’ to hold the resus team together. In any resus, it is common to delegate one person to scribe. It’s important to have a record of drugs given, interventions delivered and arrival/departure of team members etc. But many people, myself included, find that the furious writing by one team member of all events & drugs on a piece of paper that noone else can see does little to add to team effectiveness in a critically ill patient. Scott Orman over at Auckland HEMS has posted a nice summary of why a whiteboard is so useful for prehospital handover – I think this applies equally for rural hospitals.

Why is that? Well – it’s pretty simple. In a small team, we need every hand on deck – delegating a clinical member to scribe may take them out of circulation. But that’s a minor gripe – the main problem with the scribe is that noone else can see what he/she has written unless they take time out to read their notes. In short, there is no shared mental model when all documentation goes via the scribed notes. Moreover, the scribe may accurately capture all the interventions and their timing from multiple sources – but this knowledge is not shared between team members.

“often the scribe has all the critical information – noone else does!”

This makes sense – the resus can be chaotic, especially when team members haven’t trained together and there is a lack of leadership or followership, unclear role allocation nor closed loop communication. Instead there is frenetic activity, cross talk, repeated interruption and a requirement to re-hash essential elements of history and interventions with the arrival of each new team member…

This is where the resus whiteboard comes into play – I’ll be the first to admit that ours is not big enough – but it’s a start. I would hope that every rural ED has a whiteboard available at the head of the bed or adjacent. Documenting initial prehospital handover, subsequent interventions and obs, as well as arrival/departure of key players can help the whole team.

A whiteboard gives a clear indication of who did what, when, and why…as well as response to intervention. New arrivals to the resus can stand back and get a summary without having to interrupt.

More importantly, I find that having a summary on the whiteboard where everyone can see it gives a shared mental model – of where the patient was on arrival, the therapeutic goals and the steps needed to get there – a readily available shared mental model for all team members without the need for repeated interruptions and cross-questionning which is inevitable as additional team members enter the resus.

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

Rather than have to re-hash information, the whiteboard can give a quick summary of where we started, where we are now…and where we want to be.

It can also help open up communication – how much easier is if for a team member to raise a hand and ask “Excuse me team leader…I see that we have a goal MAP of 70 but the current MAP is only 55. Do you want to do X, Y, Z?” or “Hey everyone, we’ve transfused four units of packed cells in the last 20 minutes – we’re now into the agreed trigger for massive transfusion protocol…can we organise as agreed earlier per protocol?”

Of course we still need to keep a written record – I am not suggesting that the whiteboard alone will suffice – but in a resource-limited and time-critical resus, the whiteboard can truly be the glue to keep the team on target and ensure what needs to be done is done, and that everyone knows about it! Here’s how the ‘ideal’ resus flow of information would work via whiteboard…

Prehospital Notification

AT-MIST AMBO or ISBAR can be used as a structured handover tool, allowing anticipated needs to be identified and role allocation of team members.

AT-MIST : Age/Time/Mechanism/Injuries/Symptoms&Signs/Treatment provided&Trends

AMBO : Allergies/Meds/Background/Other

ISBAR : Identity/Situation/Background/Assessment/Response+Readback

Key equipment needs may be anticipated based on pre-notification eg: traumatic head injury means probably need blood, fluid warmer, TXA, RSI equipment. Drugs such as ketamine (for both analgesia and induction) can be pre-drawn and emergency drugs doses calculated & written down (especially for paediatric cases or uncommon scenarios). This is a good time to call in other staff – especially if multiple injuries or if solo operator and one critical patient. The more resus I do nowadays, the lower my threshold to call in a colleague. It’s just so much easier to share the cognitive load…

Patient Reception & Pre-Hospital Handover

Unless in extremis, take 30 seconds for a structured handover from the ambos before the patient is transferred off their stretcher. This is a high risk time. There is usually a flurry of activity as well-meaning individuals attempt to take history, remove clothes, gain IV access and set up monitoring. Seriously – stop!

Studies show that less than 50% of information relayed by prehospital services is retained by emergency department staff – this can be increased by use of a structured handover tool. Whichever handover method is used, this is a time for everyone to STFU and listen!

Unless the patient is in cardiac arrest or needs immediate intervention (airway at risk etc), take 30 seconds and use the whiteboard to confirm elements of prehospital handover history and baseline obs.

I use this to determine resus goals for the team. You will be amazed at how much information is missed at handover – especially when the receiving team ‘get busy’ with lines, blood pressure and monitoring – when they should be listening and coming up with a game plan! And don’t get me started on 1-2-3 vs ready-brace-move for the actual transfer!

Rural Resuscitation

Once obs are done and as the primary survey is completed (again, calling out the findings so can be scribed to whiteboard), ensure a shared mental model of early treatment goals is established. I don’t know about other rural docs, but I find that a rural resus is hard work – we do this stuff infrequently, yet attention to detail can make all the difference. Critical care is mostly about doing the basics, well.

Treatment goals may be as simple as “let’s keep the patient warm, maintain oxygenation, target MAP >70 and stop the bleeding” or may be a little more nuanced “Let’s secure the airway – we’ll optimise position and pre-oxygenate; use the challenge-response checklist whilst drawing up drugs – then once intubated immediately perform a finger thoracostomy and ongoing resuscitation with warm blood whilst packaging for transfer”

Obs can be scribed to show trends and response to interventions. Key times & doses of drugs given are recorded.

Having a shared mental model allows opening up of communication of goals aren’t being achieved. Rather than challenge the team leader (which can be difficult where there is an actual or perceived authority gradient), this approach allows truly patient-centric team collaboration.

Of course this will be concomitant with closed-loop communication between team members, something that is easily practiced on courses such as ETM. Subsequent or parallel scribing to clinical notes is possible when time allows.

Handover to Retrieval Team

As mentioned above, the whiteboard can serve as a good global summary for the arriving retrieval team (or indeed anyone who arrives to the resus after a period of time) and allows a structured handover with salient points highlighted. A photo of the whiteboard summary can be forwarded to the receiving facility as an initial SITREP. Whilst the camera is out, there’s also the chance to catch some selfies with long-lost friends…

Handover with retrieval – important time to exchange clinical info…and catch up with old colleagues (NB : this photo taken AFTER handover complete and patient stabilised!)

Before team arrival use any spare time to ensure all documentation is in order (if not already performed) and for notes to be written (often as the referring clinician I have been too busy to write anything until retrieval team arrive!). An ABC type transfer checklist can be a useful summary (mine runs from the letter A to the letter O!). Of course patient care should take precedence over documentation! In a real rush I’ve been known to write on the patient!

Debrief

A hot debrief can be useful after a resus. At this stage Country Health SA doesn’t routinely audit resus cases locally, which means there is little chance to improve performance not have open and honest communication on what went well and what didn’t. Most improvement will be about aspects of communication, equipment availability and use, as well as practice as a team for realistic scenarios. The feedback from peripheral team members can be very important – the volunteer ambos, the cleaner, the ward clerk…and again the whiteboard debrief can help identify any problems in patient care and improve team resilience.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

In short, the whiteboard can help improve individual situational awareness via the early establishment of a shared mental model, opening up communication between team members. There should be one in every rural ED – use it!

Whiteboards have been shown to aid the following in a resus:

task management
team attention management
task articulation and tracking
resource planning and tracking
synchronous and asynchronous communication
multidisciplinary problem solving and negotiation
team building

References

Prehospital to ED Handover (inc use of whiteboard) from Auckland HEMS http://aucklandhems.com/2012/11/26/pre-hospital-to-ed-handover/

Talbot R & Bleetman A (2007) Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J. 2007 Aug;24(8):539-42. http://www.ncbi.nlm.nih.gov/pubmed/17652672

The Importance of Shared Mental Model from TEAM STEPPS http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.html#m4SL13

Xiao Y et al (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication Ann Emerg Med. 2007 Oct;50(4):387-95. Epub 2007 May 11. http://www.ncbi.nlm.nih.gov/pubmed/17498845

Transfer Checklist A-O https://ruraldoctorsdotnet1.files.wordpress.com/2013/04/transfer-abc.pdf

TRANSFER CHECKLIST

Airway

Breathing

Circulation

Disability

Exposure

Fluids given

Gut (fasted/NG)

Haematology

Infusions

JVP (filled/under-filled)

Kelvin (temp)

Lines

Monitoring

Notes & Next of Kin

Other Stuff…

Breach of Protocol

September 18, 2015 by Tim Leeuwenburg 2 Comments

Coroners reports are interesting. I think there are many reasons for Doctors to read reports from the Coroner, although am sometimes frustrated that such reports

are a legal opinion, operating with total hindsight
usually fail to acknowledge the impact of system issues or outside influences (classically the impact of a busy shift, difficult diagnosis etc)
is an inevitable result of a death…just think how many more ‘near misses’ there are out there which do NOT attract a Coroner’s investigation but for which important lessons could be learned

This week the SA Coroner ruled on the untimely death of a young woman with a coronary artery dissection. The full report can be read here. It is certainly not my intention to criticise the clinicians involved….nor the Coroner – but the case does raise some issues. The Coroner’s recommendations were :

“The iCCnet protocol is an excellent document and the system where remotely situated doctors can avail themselves of the advice of an on-duty cardiologist is excellent if it is duly implemented. I see no need to make any recommendations in this matter.”

That is a little disappointing as I think there ARE some other issues that could be explored in such cases.

Integrated Cardiovascular Clinical Network

I’ve written about this before, but for those of you unfamiliar, iCCNet is the brainchild of Dr Phil Tideman and team (follow Dr T on twitter @heartphilt).

Recognising the difficulty of ECG interpretation for unsupported rural doc, the iCCNet team offer a true ‘one stop shop’ for all matters cardiac. A single phone line puts the rural doctor in touch with a consultant cardiologist 24/7. who can both advise on immediate management OR (sometimes more useful) smooth the referral pathway for timely investigation.

The system is supported by point-of-care testing for Troponin T levels in rural EDs, with networked results for both this and other POC tests (as lab tests may take 12-24 hr turnaround in rural Oz). It goes without saying that ECGs are also shared electronically, meaning the cardiologist can report an ECG even if local doctor cannot.

In the old days (and indeed, interstate), the rural doctor has to ring a cardiology registrar and discuss the case…all well and good, although there is considerable heterogeneity in the quality of referrals and responses. The iCCnet system mitigates against this.

It’s great that we have such a system for cardiology – my dream would be to see a similar setup for trauma radiology in country EDs, perhaps utilising the 24/7 services of the radiology or trauma service in the new Royal Adelaide Hospital…

The value of point-of-care testing is also relevant in this case – the troponin was elevated, yet in this sad case the clinician decided to ignore this and consider an alternative diagnosis. POC tests are useful – but only if the clinician considers them, or has good reason to ignore.

Why then was there a breach of chest pain protocol in this case? I don’t know – I was not there. But perhaps we should consider two more issues.

Supervision of Juniors

Firstly the potential problems with relatively junior doctors working unsupervised in rural EDs – we wouldn’t allow a PGY3 doctor see such patients in a tertiary ED see such patients without immediate onsite supervision )Ed reg consultant, labs, imaging, specialist services). Is it reasonable to expect junior MOs to work unsupervised in rural EDs? Is this fair on patients? But in the face of a workforce shortage, what else can we do? Unhelpful rules (no payment for supervisor attending) also work against safety in such matters, a fact which the Coroner did not explore in his report

Second, the fact that this breach of protocol (chest pain, raised troponin – a slam dunk for the iCCNet pathway) happened is puzzling. Whilst the attending doctor is ultimately responsible for the patient, it seems in this case that experienced nursing staff may have had concerns.

Authority Gradients & Graded Assertiveness

What I think is fascinating is that there is little discussion of the influence of human factors or resus room management in Country Health SA.

Doctors and nurses rarely train together. There is no routine in situ sim of common presentations (ACS, sepsis, confusion, psych etc), nor is there explicit training on topics such as graded assertiveness and flattening authority gradients.

Screen Shot 2015-09-18 at 10.11.56 pm — C.U.S.S. your Clinician

So…the Coroner’s report – interesting reading and of course the feeling of yet another individual failing causing harm….

If we are SERIOUS about patient safety, we’d address some system issues

take a leaf from iCCNet and establish similar services – trauma radiology is ‘low hanging’ fruit
reassess the supervision requirements of junior MOs working in rural EDs and ensure there are adequate systems to provide support (mindful of rostering, workforce, fatigue and of course remuneration)
look more closely at the impact of human factors in preventing mishap. In this case, would a graded assertiveness approach (eg CUSS) have helped the nurse engage the clinician and seek a second opinion? I think regular in situ simulation involving all members of the healthcare team, covering common ED presentations, has the potential to raise the bar significantly

In short – think of how can mitigate system failures, not individual. Plenty more work to be done in Country I think….

Country Health SA

Don’t Find A Fault – Find A Remedy

“The team that trains together will improve together”

“In sim, we debrief after every case – and yet we don’t after a real emergency”

Safety in Resus – Use the Whiteboard!

“often the scribe has all the critical information – noone else does!”

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

Breach of Protocol

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Country Health SA

“The team that trains together will improve together”

“In sim, we debrief after every case – and yet we don’t after a real emergency”

“often the scribe has all the critical information – noone else does!”

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

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