Patient safety incident reviews: sharing learning
The following information and recommendations are being shared with all facilities in the spirit of learning and improving patient safety.
The Non-Hospital Medical and Surgical Facilities Patient Safety Incident Review Panel recently reviewed an incident involving a patient who required several admissions to hospital following a procedure at a non-hospital facility. Admissions were for inadequate pain control, nausea and vomiting, and actual interventions were minimal and dealt with general medical issues.
One of the contributing factors to this incident included the patient’s lack of a social support system:
- This lack of support resulted in the patient seeking help in the hospital system and requiring 15 days of admission. The pre-operative education and assessment were inadequate to optimize the chance of success following surgery. Each assessment (RN, anesthesia, surgeon) was made with respect to whether the patient was medically fit to deal with the anesthetic, surgery, or PACU stay. No one took responsibility or assessed if this patient was appropriate for the surgery in terms of post-operative support requirements.
In reviewing the potential impact of the contributory factors on the patient safety incident, the panel made the following recommendation for the facility and others to consider:
- Consideration and assessment of a patient’s post-operative course should be undertaken by a multi-disciplinary team. Social history should be assessed as part of pre-surgical screening to determine post-operative support requirements for the patient.
Facilities are reminded that care of a surgical patient doesn’t end when the patient is discharged. Patients should be assessed for required supports following surgery to ensure a successful recovery. A social history should be included in the pre-operative assessment to allow for discharge planning.