This scenario forms part of the learning materials to support our Raising and acting on concerns decision tool

Back to the Raising and acting on concerns decision tool - Faced with a concern about patient safety, are you yourself in a position to put the matter right?

Local incident reporting arrangements

Background

Dr Baker is a haematology ST3 and works at a tertiary referral centre in London. 

Her duties include providing care to patients with sickle cell disease, which can result in organ failure or stroke. The treatment of these patients often requires the insertion of temporary central venous catheters (CVC) using 2D ultrasound.

Scenario

Dr Baker is concerned that there is no provision for formal training and assessment of trainee doctors in the use of 2D ultrasound for CVC insertion. 

Because of this lack of training, she is aware that some less experienced trainees are being asked to perform a procedure beyond their competence. 

She knows of one recent incident where a trainee did a line insertion on a patient, Mr Akintola, without using ultrasound. Fortunately, he was not harmed. But the line insertion did carry the risk for Mr Akintola of the catheter moving out of the blood vessels, and damaging the adjoining structures, potentially leading to infection as well as a risk of local bruising and bleeding.

What the doctor did.

Dr Baker discusses her concerns with her Clinical Supervisor, Dr Meena, Dr Baker feels that even though no patients have been directly harmed in any incident to date, it is only a matter of time before something serious happens. Dr Meena encourages her to complete an incident report form for the 'near miss' incident. 

A few days later, the incident report is considered by the senior management team during the weekly departmental review. The Clinical Supervisor Dr Meena is present and supports the concerns of Dr Baker. It becomes clear that a number of trainee doctors had expressed concerns, at different times, about whether they had adequate training to safely carry out 2D ultrasound CVC insertion. The team decide to make short term arrangements to improve the service, by enlisting help from the trained renal physicians to carry out some of the procedures. 

As a longer term solution they agree to implement a new training programme on the use of ultrasound for CVC insertion, to be provided to all doctors.