United Lincolnshire Hospitals NHS
NHS / Health Body
Action Taken
United Lincolnshire Hospitals NHS Trust revised antibiotic guidelines, developed a traffic light risk recognition system for penicillin allergic patients, incorporated allergy awareness into mandatory training, implemented SBAR for handovers between A&E and MEAU, and reviewed the nurse's practice involved in the incident, providing further training and competence assessment. (AI summary)
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Dear "drug
Modification of the prescription chart to state "Drug allergies and sensitivities" in a red coloured with more space to list drugs and the effects, with the source of information and completion signature_ name and date Allergy section on prescription chart before: Chart No. 2 3 5 0 Ins DRUG SENSIIVITIES No AKPA Source PHTOT 1 V QTHER INFORMATION Pa DV Patl Kn Height cm End Weight 6 ka pre= BM 37 SA Sig Aft Allergy section on prescription chart after: Enei3 Cer ORuG AlLerGies JcC sensitivities fatt Beeops allergieS sensitivines: bck box 5ot5 NEoA F7CT akn (Clcle) hurtht Hore Geher [697 Ez
2) The handover of care from A&E to MEAU is now based on a handover tool, called SBAR This is an acronym for Situation, Background Assessment and Recommendation and allows for a structured handover to take place. This approach brings consistency in communicating points of information: Within the background section is a prompt sheet for highlighting allergies SBAR has been found to improve communications between members in different clinical areas ie A&E Vs wards_
3) has been referred to the General Medical Council
4) The Trust's Interim Director of Nursing has reviewed the professional conduct and implications in relation to the registered nurse involved. This included reviewing the available information from the time of the event in 2009. At the time of the event in 2009, the nurse's practice and competence in administration of Chairman: Paul Richardson MINDFUL Chief Executive: Jane Lewington EMPLOYER title , JonA key Abou; "jAdLt9
medicine was reviewed and a training update undertaken. Since that time, the nurse's practice has been without any further incident: Following the inquest; the nurse's practice was further considered and taking into account the impact of the inquest on the nurse she was restricted from involvement in medicines administration for a short period of time to protect both patients and herself. She has since received further training and competence assessment; which she passed without concern: With reference to your query about referral to professional regulators, the Interim Director of Nursing can confirm that she has discussed this case in detail with Nursing and Midwifery Council. This discussion included reference to actions already taken by the Trust. The discussion concluded with the Council's confirmation that will review the case_ If you require any further information, would be to liaise with you directly.
Modification of the prescription chart to state "Drug allergies and sensitivities" in a red coloured with more space to list drugs and the effects, with the source of information and completion signature_ name and date Allergy section on prescription chart before: Chart No. 2 3 5 0 Ins DRUG SENSIIVITIES No AKPA Source PHTOT 1 V QTHER INFORMATION Pa DV Patl Kn Height cm End Weight 6 ka pre= BM 37 SA Sig Aft Allergy section on prescription chart after: Enei3 Cer ORuG AlLerGies JcC sensitivities fatt Beeops allergieS sensitivines: bck box 5ot5 NEoA F7CT akn (Clcle) hurtht Hore Geher [697 Ez
2) The handover of care from A&E to MEAU is now based on a handover tool, called SBAR This is an acronym for Situation, Background Assessment and Recommendation and allows for a structured handover to take place. This approach brings consistency in communicating points of information: Within the background section is a prompt sheet for highlighting allergies SBAR has been found to improve communications between members in different clinical areas ie A&E Vs wards_
3) has been referred to the General Medical Council
4) The Trust's Interim Director of Nursing has reviewed the professional conduct and implications in relation to the registered nurse involved. This included reviewing the available information from the time of the event in 2009. At the time of the event in 2009, the nurse's practice and competence in administration of Chairman: Paul Richardson MINDFUL Chief Executive: Jane Lewington EMPLOYER title , JonA key Abou; "jAdLt9
medicine was reviewed and a training update undertaken. Since that time, the nurse's practice has been without any further incident: Following the inquest; the nurse's practice was further considered and taking into account the impact of the inquest on the nurse she was restricted from involvement in medicines administration for a short period of time to protect both patients and herself. She has since received further training and competence assessment; which she passed without concern: With reference to your query about referral to professional regulators, the Interim Director of Nursing can confirm that she has discussed this case in detail with Nursing and Midwifery Council. This discussion included reference to actions already taken by the Trust. The discussion concluded with the Council's confirmation that will review the case_ If you require any further information, would be to liaise with you directly.