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Table 3 Cohort 2017: summary outcomes (total 330 of which 22 errors)

From: Developing Healthcare Team Observations for Patient Safety (HTOPS): senior medical students capture everyday clinical moments

Code theme

E = error (numbers in italics)

T = threats or concerns

Description

Error for infection-relating to staff

E = 8

T = 44

Errors

• Nurse removes clips wearing gloves but bin not working so touches with her gloved hand and then checked patient wound (× 2).

• Consultant on the phone in personal protective equipment (PPE) leaves isolation room still wearing PPE (× 2).

• Operating department practitioner started an incident investigation for non-sterile equipment in theatre (× 2).

• Patient had diarrhoea for 3 days and no stool sample taken.

• Failure to gown up properly in an MRSA area—infection control told.

Other examples of threat concerns

Not hand washing

• Doctor did not wash hands before entering the bed space and examining the patient.

• Ward round no one washed hands between patients.

Practitioners coughing, sneezing

• Consultant sneezes into hands and proceeds to touch iphone, obs chart and patient’s bedside.

No equipment to support handwashing

• No alcohol hand gel in bay areas to wash hands.

• Physio equipment blocking access to hand gel—no hand washing.

Poor infection control awareness

• Theatre staff repeatedly brushing against non-sterile parts of the theatre.

Staff related

T = 16

Stretched Staff

• Junior doctor in a hurry left with two pagers when on call.

• Registrar taken from ward round but knowledge was vital.

• Too many patients on a theatre list.

Health and safety

T = 4

• Sharps bin not secure.

• Wet floor in theatre not wiped.

Patient notes

T = 10

• Midwife unable to read doctors writing.

• Patient could not be discharged as notes missing.

Similar patient names

E = 1

T = 4

Error

• Wrong patient—brought one with the same name.

Laterality

T = 1

• Incorrect limb labelling.

Privacy, dignity and confidentiality

E = 1

T = 45

Error

• Patient not involved in consultation. All advice and explanations were given to the relative; there were no mental capacity issues. Lack of patient involvement meant no ability to raise concerns.

Other examples of threat concerns

• Discussing patient in a corridor patient overhears and states ‘that’s me’.

• Finally a scrub nurse covers patient but left exposed unnecessarily.

• Imaging software prompts for password after user name entered.

Computer related

T = 24

• Had to get x 3 computers to try and access a radiology image.

• Ward round delayed as no portable computer.

Escalation and patients waiting

T = 2

• Patient no referred quickly from A/E and could not receive care available—cause of delay unknown.

Risks from poor practice

E = 1

T = 2

Error

• X-ray showed patient had a bracelet on under her plaster.

Other examples of threat concerns

• Cast removed and pressure sore apparent.

Language

T = 10

• Mother with no English did not know to prepare child for pain on removal of K-wires.

• Deaf patient had to rely on lip reading.

Not thinking

E = 2

T = 9

Error

• WHO check list all done from memory (× 2).

Other examples of threat concerns

• Removal of K-wires form child without checking how many were there.

• Junior doctor reads patients S number from memory.

• Imaging not consulted before K-wires removed.

• Not checking who was in the clinic assumed it was the husband.

• Patient in fracture clinic can be with nurses, X-ray etc. and there is no record of where they are.

Team issues

E = 5

T = 24

Errors

• White board recording swabs and operation equipment was wiped clear before final count and end of operation.

• Trainee junior doctor missed the introductory huddle and WHO theatre check and goes onto conduct procedures despite not knowing the team and what was going on.

• Breakdown in communication advanced nurse practitioner in the community had left bandages on too long—poor dialogue between the teams.

• WHO checklist not read out and considered in theatre (× 2).

Other examples of threat concerns

• Team briefing using a structured check list was interrupted by midwives swapping places so neither heard the entire brief.

• Poor communication between doctor and nurse, ‘Nurse you sort this out’ what?

• Use of jargon in a team juniors did not understand.

Environment/design

T = 40

• Clock incorrect in theatre.

• Poor place for discussion and group huddle were interrupted with people walking through.

• Fracture clinical no space for people in wheelchairs.

• Clinic so hot pregnancy mothers have fainted.

• Physiotherapists and plaster technicians share a room—no privacy and plaster equipment a hazard for the patients and physios.

Drug related

E = 3

T = 4

Errors

• Patient left on a medicine (Tamsulosin) after a Transurethral Resection of Prostrate when no longer needed. Patient now come in for a cataract operation—error noticed.

• Junior Doctor prescribed the wrong dose the pharmacist corrected before administration.

• Drugs drawn up and forgotten about the consultant anaesthetist notices and asks the core trainee what it is for and gives the drug—poor communication chatting.

Other examples of threat concerns

• Cannot read prescription.

Recording clinical information and consent

T = 5

• Foetus scan incorrect.

• Consent where anaesthetic risk not mentioned and patient given unclear information about operation risks.

Investigation related

E = 1

T = 4

Error

• Radiology error: In this case patient had a ring block for manipulation of a fracture but it was not a fracture.

Other examples of threat concerns

• Insufficient X-ray view obtained.

Equipment related

T = 10

• Wrong bed type for operation—had to be changed.

• Use of a radiator for placing equipment as not enough space or trolleys in the room.

Poor professionalism

T = 21

• Registrar answers a phone inform of patient and walks out no explanation.

• Patients notes not in trolley—they were in the wrong slot—took 4/5 staff several minutes to find them—but easy to put back in the right place.

• Radiographer and ODP talking and joking over a patient under local anaesthetic.

Checking

T = 9

• Points for patients ID × 3 point check.

• Wrong patients imaging results checked but was spotted long chain of repeating numbers… too many digits.

• Missing test results.

• Difficult to read handwriting.

Organisational issues

T = 4

• Clinic too many doctors today but the other day too few—disorganisation of the clinics.

• Multiple copies of a patients notes—they had been duplicated.

• Organisation of notes from trolley to desk in outpatient clinic chaotic.

• Only one key to medicines cabinet—could not find nurse with key.

Distraction

T = 18

• Lots of background noise while WHO check list being done—not everyone could hear.

• Registrar having to leave patient on several occasions to take phone calls.

• Consultant writing notes frequently interrupted with questions.

• Wrong notes brought to patient room.

• Lack of read back different members of the team meet and are not discussing the same patient—different S numbers.

• Towards end of surgery lots of different conversations going on at once—staff just focussing on individual tasks this is probably because it has been a long procedure.