East Midlands Ambulance Service - Serious Inside Report - March 2013
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Transcript of East Midlands Ambulance Service - Serious Inside Report - March 2013
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Time Required 10 mins Paper No. PB/13/46
Report to: PUBLIC BOARD OF DIRECTORS MEETINGDate: 25 March 2013
Subject: Serious Incident (SI) Performance Report
Report by: Karen Glover, Director of Nursing and Quality
Purpose of Report
To provide a summary of the Trusts performance against key targets for the reporting andmanagement of serious incidents.
It also provides a thematic analysis on serious incidents reported by the Trust to date and
details lessons learned and action taken in response to mitigate risk.
Implications:Quality (including Patient Safety, Staff Safety, Dignity and Patient Experience)
Ensuring learning from serious incidents is implemented wherever possible for serviceimprovement
Human Resources including Equality
N/ALegal
N/APolicy
N/AFinancial (including any funding requirements)
N/AMedia/Communications
Poor performance meeting the 2 working day reporting deadline could potentially leaveTrust vulnerable
Details of any identified risk(s):
Non timely completion of SI actions
Risk AssessmentConsequence(A)
Likelihood (B) Score (A x B)
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The table below shows Divisional performance (numbers in brackets indicate near misses):
DIVISIONAL
PERFORMANCE
YTD (as of 28/2/13)
Derbyshire
Emergency
OperationsCentre(EOC)
Leicestershire & Rutland
Lincolnshire
Northants Nottinghamshire
Other e.g.Trust/HART YTD Total
Total Number SIreported(includingnear misses and NEs)
4 25 (4) 4 7 (1) 8 3 2 (1) 53 (6)
Reported as SI, thendowngraded
2 1 1 0 1 1 0 6
Local Never Events 1 0 0 1 1 0 0 3
% reported to thecentral team within 1working day
100%(4/4)
60% (15/25) 50% (2/4) 85% (6/7) 87% (7/8) 33% (1/3) 1 (1/2)67%(36/53)
Of the 25 EOC reported incidents 15 are as a result of lack of Divisional resource and can be represented as follows:
Derbyshire Leicestershire &Rutland
Lincolnshire Northants Nottinghamshire Other e.g.Trust/HART
4 2 3 2 4 0
4.0 Open SI Investigations
The table below provides a summary of all 27 open serious incidents as at end of February. This includes 4 that remain open following submission
to the Commissioner for closure.
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Level of Harm Key:
1 No harm/ near miss
2 Minor harm- requires minor treatment/ remains independent
3 Moderate harm- requires hospital treatment/ no permanent harm4 Severe harm- permanent injury/ requires help with activities of daily living
5 Death
Theme Source
of SI
Division Call
Category
Level of
harm/patientoutcome
Date on
STEIS
Description Immediate action taken
CareManagement
PALSConcern
Notts Red1 1 22/02/2013 Care Management:Paramedic attended patientwith chest pain and difficultyin breathing. There wereconcerns regarding theParamedics attitude and care
management The patient wasadmitted the following day onto an acute cardiac unit atCity Hospital.
Paramedic stood down frompatient-facing duties andinvestigation commenced
CareManagement
Divisional Director
North Red 2 3 20/02/2013 The following two incidentsinvolve one EMAS paramedicand occurred on the sameday.
Incident 1: CareManagement. EMAS calledto attend a 68 year old femalewho was found on the floor(24hr+). The lady was notsuitably immobilised and theEmergency Care Assistantprovided care in transit with
no pre-alert. The lady waslater found to have a broken
Paramedic stood down frompatient facing duties andinvestigation commenced.
Police and EMAS SafeguardingTeam involved(Incident 1)
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
three ampoules of morphinewere left on the roof of a
response car by a paramedicprior to driving away.Retrieved by a member of thepublic who had found themby the roadside nearby.
Competency/knowledge of staff
involved assured before return tooperational duties.
Local NeverEvent
IR1 Northants Green 2 2 14/01/13 Never Event RTC: DCA crewwas transporting a patientwith a suspected fracture
neck of femur (NOF) on aspinal board to hospital.Whilst en route the side of theambulance stretcher gaveway resulting in the patientand spinal board falling offthe stretcher onto the floor ofthe ambulance.
On initial investigation therewas no five point harnessfitted to this stretcher and thecrew reported that thestretcher side bar pin is worn.
This has been reported as aLocal Never Event.
Stretcher removed from vehicleand collected by fleet15/01/2013. Report indicated no
fault or concern with thestretcher.
Patient visited by EMAS staff.Patient sustained no furtherinjuries from incident.
Initial review vehicle had no 5point harness. This had been
removed by PTL prior to12/01/2013 due to being heavilysoiled.
Safety bulletin issued to all staff
Safe Carriage SOP revised
Vehicle check sheet for this
vehicle has not been located.
IR1 completed by crew.
A 72 Hour report was submittedto Commissioners.
Incorrect CallCoding
PALS EOC Red 1 5 11/01/13 Incorrect Call Coding: A callwas received reporting a carhad gone in to the central
reservation wall on a bridge.The caller stated smoke was
Call audits requested as part ofinvestigation standard procedure
Correct procedures reiterated tocall taker
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
coming from the car and oneperson was in the car. That
person was possibly trapped.The call was coded TrafficAccident Green 1 20 minuteresponse.
As an entrapment had beenmentioned and informationprovided that the patient wasnot alert. This should have
been coded as a Red 2. Alater call by the fire servicestated that CPR was inprogress (16 minutes afterthe initial call).
DelayedTreatment
IR1 EOC Red 2 0 10/01/13 Delayed Treatment:AMVALE Crew verballyallocated and dispatched toattend a Red 2 call for a
patient at a Care Home.AMVALE crews do not haveMobile Data Terminals (MDT)and normally update time ofarrival once clear from anincident. A second call wasreceived from the Care Home18 minutes later asking forETA. A secondary call sign
was allocated attended andconveyed patient to hospital.Patient outcome unknown.
Initial investigations indicatedAMVALE crew returned to basebelieving they had been stooddown by control. This was
approximately 45 minutes priorto the shift ending. Control wasnot aware of this information.
Amvale notified to reinforcecorrect procedure to all their staff
CareManagement
IR1 Lincs Red 1 5 09/01/13 Care Management:Ambulance called to attend a44 year old patient in cardiacarrest. Patient found to be inthe bath on crew arrival.Patient removed from bath
and CPR commenced.Paramedic back up was
Police involved as possiblesuspicious circumstances.
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
approx. 40 minutes.
During subsequent journey toonward Acute Trust patientsuffered respiratory arrest.
InformationGovernance
IR1 Northants N/A N/A 07/01/13 Information Governance:On way to standbyParamedic opened window ofcab. A gust of wind carried aPRF out of the window.
Crew was unable to stop tolocate paperwork.
Investigation commenced.
Crew reminded to removepaperwork from vehicles as soonas possible and to storeappropriately in vehicles.
Missing Drugs IR1 emailfromDivision
Lincs N/A N/A 04/01/13 Missing drugs: Adiscrepancy with Codeinetablets has been reported atLouth and SkegnessAmbulance Stations.
Police notified
Review access and storage ofmedicines management carriedout by Division
IncorrectCoding
FC EOC Green 2 andRed 1
Not known 04/01/13 Incorrectly coded: Callreceived for a 50 year oldfemale and incorrectly coded
Second call correctly codedas Red1.Patient transferred to hospitalwith pre-alert to hospital.
Feedback provided to call takerto reinforce correct codingprocedure
Delayed
Response
R1 EOC Green 2 Unknown 03/01/13 Delayed response: Call
received from a member ofthe public for a male withfacial injuries. Due to high999 demand call held for 1hour 7 minutes.
The first available crewarrived on scene 1 hour 12minutes after the call was
made.
Call audits requested as part of
investigation standard procedure
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
CareManagement
Coroner Leicester-shire
Red1 5 21/12/12 Death in Custody.Crew attended a patient at
the Magistrates Courtfollowing attempted hanging.
On arrival crew attemptedAdvanced Life Support. Theintubation was later found tobe oesophageal rather thantracheal.
Consideration given to standingcrew down but not considered
necessary all protocols werefollowed and no caremanagement failure indications
InformationGovernance
IR1 Trust N/A N/A 13/12/12 Information Governance:A contractor working on theTRACE computer system,which administers the leasecar fleet, saved some data tohis personal web spaceduring a period ofmaintenance.
An EMAS student alerted theTrust to the fact he haddetected that personal detailswere freely accessible on theinternet
Document removed from theserver.
Third party contractorinterviewed by IG and ICTmanagers.
Notification to all Staff involvedbeen sent out.
Trust IG Lead informed
Information Commissionernotified
Road TrafficCollision
IR1 Lincs A&E Green 2 5 11/12/12 Road Traffic Collision
999 call to assist patient whohad fallen out of bed &sustained a leg laceration &head injury.
En route to the hospital,travelling at normal roadspeed the vehicle veered offthe road with the patient on
board. Patient sustained ahead injury and died.
Investigation delayed due toPolice investigation. Staff cannot
be interviewed as medically unfitand currently absent from work.The investigation will exceed the60 days timeline for submission.It has been marked as out of ourcontrol by the PCT.
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
CareManagement
PALS Notts A&E Green 2 5 11/12/12 Care Management:
999 call to attend an elderlymale patient having fallen inthe bath & sustained a headinjury. Alleged caremanagement failure centeredon inadequate assessment ofpresenting condition. Patientdied in ED.
Crew stood down from patientfacing duties.
DelayedResponse
Coroner EOC Urgent 5 29/11/12 Delayed response: 4 hourUrgent call was received at14:50 for a 76 year old withUTI & uncontrolled diabetes.Ambulance on scene at21:27. Patient deterioratedand died in hospital.
Call audits requested as part ofinvestigation standard procedure
Equipment
Failure
EMAS
PTLemail
Northants
A&E
Red1 5 27/11/12 Equipment failure:
Paramedic attended acardiac arrest. Duringresuscitation noticed that thepatients chest suddenlybecame rigid & he wasunable to ventilate. Patientdied.
All T-pieces removed from all
Divisions
Referral to MHRA
Clinical bulletin issued
Crew not stood down asdetermined that no patient safetyrisks remained
DelayedResponse
IR125248
EOC GP Urgent 5 24/10/12 Delayed response: Callreceived as an urgentbooking (4 hours requested)at 16.45 for a patient withurinary retention. Due to highdemand, patient was notcollected within the giventimeframe. At 20.54 contact
was made with the NursingHome. A Nurse at the
Investigation commenced
Call audits requested as part ofinvestigation standard procedure
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
location was offered theoption to upgrade the booking
to an emergency call, butadvised the EMD the patientcondition did not warrant anupgrade.
At 22.02 an ambulance hadstill not been allocated on theurgent booking. Anemergency call was received
from the Nursing Home toadvise the patient had aDNAR and had died. Theystated that an ambulancewas no longer required.
IR1 Delayed
Treatme
nt
Notts Urgent 5 10/09/12 Delayed Treatment Patient
required transfer via Bariatric
vehicle. Vehicle found with no
power to the rear saloon.
Following temporary repair
arrived at the patients home
3 hours after initial
assessment. Patient
condition deteriorated on
handover and later died in
hospital
Review of Trust-wide bariatriccapabilities has beenundertaken by Commercial
Director
SDM ensured cascade trainingto PTLs and crew involved forMegasus Stretcher and VikingHoist
Bariatric vehicle inspected andapproved as roadworthy
PTLs trained in use of bothbariatric hoist and stretchers forcascade training- evidencerequested to demonstrateclosure of this action
InappropriateActions
Police Derbys N/A N/A 01/06/11 Inappropriate Actions: 23year old female attended apolice station in May and
made a safeguardingallegation against a member
Staff member initially stooddown pending investigation
Case investigated by the policeno charges brought
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Theme Sourceof SI
Division CallCategory
Level ofharm/patientoutcome
Date onSTEIS
Description Immediate action taken
of EMAS staff.Staff member returned to duty
once EMAS satisfied it wasappropriate to do so
5.0 Trust Themes
The following table and graph show themes since 1st April 2012. Numbers in brackets indicate near misses.
THEMES 2012/13Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb
YTD
Total
2011/
12
Allegation against HC Professional 3
Breach of Confidentiality 1 1 2 2
Care Management 1 1* 1 2 4 3* 3 15** 13# (6)
Delayed Handover 4
Delayed Response 2 1 1 1 (1) 1 1 (1) 3 1 2 13 (2) 19## (3)
Incorrect code/Delayed Treatment 1 1 1 1 2 1 4 11 2
Drug Management/Loss 3 3 #
RTC 1 (1) 1 1* 3* (1) 3 (1)
Safeguarding Allegation 1 1 0
Service Failure 1Vehicle Incident 1 1 (1) 1 3 (1) 1 (1)
Patient/staff accidental injury 1 1 2
Patient Abscond 1 1
Grand Total (Near Miss) 3 (1) 5 2 1 3 (1) 3 5 (2) 8 7 13 3 53 (4) 50 (11)
Downgraded SIs 1 3 1 1 6 4
Never Events 1 1 1 3 0*Shows never event # shows downgraded incident 2011/12
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Staff are now routinely temporarily stood down from patient facing duties following care management Sis until such time as their safety to
practice can be confirmed. This may be following appropriate retraining or competency assessment. Dates of last appraisal and Essential
Education are identified as part of the investigation process and if these have not been undertaken in the previous 12 months the
individuals are prioritised.
Revision of the Safe Carriage SOP to make staff responsibilities with regard to safely securing patients clear and clarify action to be taken
if patients cannot be adequately secured. Introduction of a C Spine assessment and management training video podcast.
RTC
Re re-categorisation of RTC from R2 to R1 with associated QIA approved by TEG
Process for ensuring driver reassessments following RTCs strengthened
Drug-related incident Deep dive review of all drug related SIs being undertaken by the Head of Clinical Audit, Governance & Research (Accountable Officer for
Controlled Drugs) for April QGC
Reminder of responsibilities relating to medicines management included in Clinical Update email
Breach of confidentiality
Deep dive review of all information governance related SIs being undertaken by the Information Governance Manager for April QGC
Article included in the CEO bulletin to reinforce crew responsibilities in relation to information governance
Incorrect coding
Deep dive review undertaken by Patient Safety & Experience Manager and presented to February QGC and associated action plan being
monitored by Clinical Governance Group until closure.
8.0 Patient Safety Harm Rates
The chart below shows the level of harm for all patient safety incidents including Sis since 1 st April 2012. It should be noted that the level of harm
cannot necessarily be attributed to acts or omissions by EMAS staff. Other factors may prevail e.g. patients preexisting condition.
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No harm
24%
Minor
47%
Moderate
24%
Severe
3%
Death
2%
No harm
Minor
Moderate
Severe
Death
One indicator used by some organisations as a safety measure is the number of SI as a percentage of the total PSIs reported. The table belowshows the comparison between 2011/12 and the current year to date. It is important to note the year to date percentage is highly likely to go downdue to retrospective IR1 data entry.
2011/12 2012/13 to date 28 FebPSI total 150 120SI Total 50 53SIs as percentage of PSIs 33% 44%
9.0 Never Events
Never events are defined as
serious, largely preventable patient safety incidents that should not occur if the available preventative measureshave been implemented by healthcare providers. To be a never event, an incident must fulfill the following criteria:
The incident has clear potential for or has caused severe harm/death.
There is evidence of occurrence in the past (i.e. it is a known source of risk).
There is existing national guidance and/or national safety recommendations on how the event can be prevented and support for
implementation.
The event is largely preventable if the guidance is implemented.
Occurrence can be easily defined, identified and continually measured
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EMAS has not had any nationally prescribed Never Events year to date.
The Director of Nursing and Medical Director have agreed the following Never Events for contractual inclusion in line with other ambulance
services in the Midlands and East SHA region
Patient falling or jumping from moving vehicle
Patient falling from an ambulance trolley
Ambulance involved in a blameworthy fatal collision (either pedestrian or other vehicle occupant)
EMAS have reported no Local Never Events in February 2013.