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Revalidation in Wales

Mock secondary care entry - significant event

These are examples of an SEA and QIA activities treated in three ways, as the previous examples.

Again the aim is to try and show how from the same activity different levels of learning outcome and reflection can be gauged from the entry.

Significant event (1)

Date and title of event January 2020
Description A patient booked for an elective shoulder replacement was anaesthetised by me after a colleague had given them a local anaesthetic shoulder block. However, when the surgeon came in to check their positioning they noticed an infected looking area on the lower leg under a dressing. Patient was cancelled by the surgeon and I woke her up.
Outcome The patient was spoken to by the surgeon in recovery and they spoke to the ward. A Datix form was filled in.
Reflection and action Clearly the ward had not noticed the patient had a leg infection despite her having been admitted the night before surgery. The surgeon admitted this was not my fault.
Comments This is a bare statement of facts of the incident and they are presented in a very objective way. It would be appropriate to attach a copy of the Datix form, even if they did not fill it in personally. A little more detail about events might help the appraiser gain an insight in to how the system allowed this to occur and therefore lead to a more useful discussion with the doctor. The outcome would be more informative if there was some discussion of the patient’s feelings about the event and there is no indication whether the doctor saw them later when they were fully awake to offer their apologies and explanation. If these were done, as they should have been, they should be documented. Along with their own feelings about the event. There is very little reflection on the case apart from pointing out that the doctor was not to blame. The reflection should really cover how the doctor might contribute to ensuring such an upsetting error doesn’t happen again. Despite it not being their job, personally, to check there are no contraindications to joint replacement surgery, it might lead them to change their own practice in future to add an extra level of protection. They could have reflected that they are all part of a team in theatres whose job it is to ensure that patient safety is paramount. These issues should, hopefully, be covered by the appraiser in the appraisal discussion to make the event truly a learning one for all and to turn this entry into a more useful one for both the doctor and their RO.

Significant event (2)

Date and title of event January 2020
Description A patient booked for an elective shoulder replacement on a list I was anaesthetising was admitted onto an orthopaedic ward the night before and seen by me that evening for surgery the next day. She arrived in the anaesthetic room having had a local anaesthetic shoulder block put in by a colleague and our routine checks and monitoring were commenced. I then anaesthetised her and we requested the surgeon’s presence to assist in positioning the patient for the procedure. During this, a dressing was noted on the patient’s lower leg and when the surgeon removed it an infected-looking skin wound was found. The surgeon immediately cancelled the operation and I was asked to wake the patient up. I woke the patient and took her to recovery where the surgeon said they would speak to her. I spoke to her myself later and apologised that she had not had her surgery due to an error on the ward.
Outcome The patient was spoken to by the surgeon in recovery and they also spoke to the ward. A Datix form was filled in (attached). The ward sister apologised to the surgeon and the patient and assured them that the pre-operative checklist would be given more close attention in future.
Reflection and action I found this event quite stressful as I had given a patient an unnecessary general anaesthetic, which is never without risks. I have been assured that the ward will tighten their pre-operative checks and similar events should be prevented. Despite it not being my job, I am now conscious that I should be aware of things such as skin dressings on patients if they are unexpected findings.
Comments The doctor has provided a fuller account of the circumstances of the event that allow the appraiser, who may not work in theatres, to get some insight into how things transpired and how such a serious omission could have occurred. The doctor has attached a Datix form of the incident to demonstrate ‘official’ record of the event which makes the entry more verifiable. A fuller description of the wider outcome for all concerned is welcome and shows how such incidents often affect a larger group of colleagues than just the doctor and their patient. The reflection entry now demonstrates they have appreciated that they can contribute to reducing the likelihood of this happening again.

Significant event (3)

Date and title of event January 2020
Description A patient booked for an elective shoulder replacement on a list I was anaesthetising was admitted onto an orthopaedic ward the night before and seen by me that evening for surgery the next day. She arrived in the anaesthetic room having had a local anaesthetic shoulder block put in by a colleague for post-operative analgesia and our routine checks and monitoring were commenced. I then anaesthetised her and we requested the surgeon’s presence to assist in positioning the patient for the procedure. During this, a dressing was noted on the patient’s lower leg by my ODP and when the surgeon removed it an infected-looking skin wound was found. The surgeon immediately cancelled the operation as the presence of infection is a contraindication to joint replacement and I was asked to wake the patient up. I woke the patient and took her to recovery where the surgeon said they would speak to her. I spoke to her myself later and apologised that she had not had her surgery due to an error on the ward. I told her that the surgeon would speak to her later to explain the about the high risks if we had proceeded with the operation.
Outcome The patient was spoken to by the surgeon in recovery and they spoke to the ward. A Datix form was filled in (attached). The ward sister apologised to the surgeon and the patient and assured them that the pre-operative checklist would be given more close attention in future. The colleague who put in the shoulder block was also informed about this and said he was available if the patient had any questions about his involvement.
Reflection and action I found this event quite stressful as I had given a patient an unnecessary general anaesthetic, which is never without risks. They had also had a shoulder block which can take many hours to wear off and make the arm involved effectively useless in that period. I have been assured that the ward will tighten their pre-operative checks and similar events should be prevented. The whole team has reflected on the event and are all much more aware of how such things as a dressing on a patient may affect the surgical outcome and as it was the ODP who spotted it. This is a reminder that safety in theatres is everyone’s responsibility. Although it is not technically my specific responsibility to check for similar problems, I am now conscious that I should be aware of things such as skin dressings on patients if they are unexpected findings and voice those concerns as early as possible to prevent such events happening again.
Comments This entry is a much more complete account of events and demonstrate further how many people can be a part of significant events. The Datix is included for the sake of clarity and validation. The outcome is more complete as it takes in more of the consequences of the event. This time the doctor has documented their wider reflection and that of the team involved. They have shown how a significant event can affect a whole team and how they can all learn to be more safety conscious in future.