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Quality & safety Serious incidents
The London Clinic is committed to providing the highest levels of care to its patients and has dedicated significant resources to ensuring that this safe care is sustainable and resilient. Despite our best efforts, incidents do happen. When things go wrong, we will always ensure that everything is done to learn from incidents and to protect our patients and staff through rapid response. Through this response we learn and improve, so that the risk of the same incident occurring again is minimised.
What is a serious incident?
A serious incident is where a harmful event involving a patient, staff member, external contractor, equipment, or anything else we need to monitor, occurs unexpectedly.
Recent incidents
What happened
What we did immediately
What we learnt
CASE 1
A consultant asked a member of the healthcare team to chaperone a procedure that was considered inappropriate for the patient. This made the staff member feel very uncomfortable. The staff member reported the incident to their line manager who immediately escalated this to the clinical site team.
• A Rapid Review was undertaken the next working day with a multidisciplinary team
• Contact was made with the patient to offer advice and support
• The staff member’s wellbeing was supported by senior nursing staff
• An investigation was immediately undertaken.
• This is a good example of the rationale for a trained chaperone to be present for all procedures to safeguard patient privacy and dignity
• The escalation processes worked well with staff feeling supported by the senior team
• The chaperone policy and training have been reviewed to ensure they meet current best practice guidance.
CASE 2
The patient was admitted as a day patient
for bone marrow aspirate under conscious sedation. Two syringes were placed on the same trolley, one with 10mg of Midazolam
in a 10ml syringe and the other a 10ml saline syringe. 6mg of Midazolam was administered, leaving 4mg of Midazolam left unused in
the syringe. A health care professional was asked to take blood from the patient. After the cannula was flushed, the HCP realised they had used the remaining 4mg of Midazolam instead of the saline flush. The patient was rousable and recovered sufficiently to go home later the same day.
• Patient immediately assessed by a doctor and closely monitored until awake and alert. Later discharged safely with family
• Patient was informed we had made a mistake, apology given and kept updated throughout.
She and family felt very reassured by our openness
• Incident was deemed serious. A review was conducted to ascertain immediate actions and lessons identified.
• A positive example of duty of candour, to be open and honest with patients
• All syringes must be labelled
• The conscious sedation policy was reviewed to ensure it meets current best practice
• The training package provided to practitioners to support the conscious sedation pathway was reviewed, and the policy updated to ensure it was in-line with Royal College of Anaesthetists guidance.
16 A more complete kind of care
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