Doncaster Bassetlaw Teaching Hospital
NHS / Health Body
Action Planned
Doncaster and Bassetlaw Teaching Hospitals are training individuals as scribes, obtaining a software update for monitors, and have set up a working group with ED and Anaesthetics to explore the issue of IV drug administration in emergencies during resuscitation. The clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status. (AI summary)
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Dear Ms Mundy Re: James Robert Quinton (Deceased) DOB: 03.01.1975 ~ DOD: 14.03.2017 write in response to Regulation 28 Report 'Prevention of Future Deaths' dated 22 February 2018 sent to the Chief Executive of Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust and for which thank you: note your concerns as follows;
1. Poor quality nursing notes and lack of information on the observation chart making it difficult for reviewing consultants to clear picture of events that had been occurring: 2 In the course of resuscitation which was supposed to be given by infusion was given as a bolus raising the question of the wrong drug or the wrong amount of drug of the wrong method of administration occurring when drugs are prescribed in such scenario on a verbal basis only: have been assisted by Matron, Emergency Department (ED) and ED Governance Lead in constructing this response: get drug
would respond as follows;
1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department: The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the resuscitation. The Emergency Department is also in the process of obtaining a update of the software on the current monitors in order to allow automatic printing of the observations in the course of the procedure: am informed by that a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end f April to look at systems and processes for working together within the Resus area. understand that the IV Administration has also been sent to all qualified staff in the emergency department,
3. Matron Sidwell has also advised me that the clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status take this opportunity to enclose for your awareness the relevant policies which are available on the Trust Intranet Safe and Secure Handling of Medicines PATIMMIa Safe and Secure Handling of Medicines Policy Controlled Drugs PAT/MMIb Injectable Medicines Policy PAT/MMS trust that the contents of this letter will reassure you that the Trust has taken steps to minimise the risk of a recurrence of the events outlined in the PFDR document Please do not hesitate to revert back to me should you feel that there are any outstanding issues.
1. Poor quality nursing notes and lack of information on the observation chart making it difficult for reviewing consultants to clear picture of events that had been occurring: 2 In the course of resuscitation which was supposed to be given by infusion was given as a bolus raising the question of the wrong drug or the wrong amount of drug of the wrong method of administration occurring when drugs are prescribed in such scenario on a verbal basis only: have been assisted by Matron, Emergency Department (ED) and ED Governance Lead in constructing this response: get drug
would respond as follows;
1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department: The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the resuscitation. The Emergency Department is also in the process of obtaining a update of the software on the current monitors in order to allow automatic printing of the observations in the course of the procedure: am informed by that a working group has been set up with representation from ED and Anaesthetics to explore further the issue of IV drug administration in emergencies during resuscitation. The first meeting is scheduled for the end f April to look at systems and processes for working together within the Resus area. understand that the IV Administration has also been sent to all qualified staff in the emergency department,
3. Matron Sidwell has also advised me that the clinical educator is reviewing IV competencies for staff within ED in relation to their current revalidation status take this opportunity to enclose for your awareness the relevant policies which are available on the Trust Intranet Safe and Secure Handling of Medicines PATIMMIa Safe and Secure Handling of Medicines Policy Controlled Drugs PAT/MMIb Injectable Medicines Policy PAT/MMS trust that the contents of this letter will reassure you that the Trust has taken steps to minimise the risk of a recurrence of the events outlined in the PFDR document Please do not hesitate to revert back to me should you feel that there are any outstanding issues.