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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 - Can the matter be dealt with through routine local incident reporting arrangements?

Reporting incidents and raising concerns

Background

Dr Khan is an associate specialist on a routine ward round on a geriatric ward.

Scenario

Mr Brooks, an elderly patient, complains of pain at the site of his cannula which, on examination, Dr Khan notices has not been inserted correctly and is not functioning as it should. 

He removes it immediately. It is clear that Mr Brooks has not been getting the necessary fluids and has been put at a heightened risk of pain, dehydration and infection.

What the doctor did

Dr Khan talks to Senior Sister Middleton about the incorrectly inserted cannula. Sister Middleton is aware that there are some new nurses working on the ward and, after making enquiries, discovers that the nurse who had inserted the cannula was unsure whether she had done so correctly, but had not sought help at the time.

Sister Middleton speaks with the other new nurses and reviews their skills in cannula insertion, which are all to a high standard. Sister Middleton and Dr Khan agree that this is solely a competence issue relating to one individual nurse, and therefore completing an adverse event report would not be appropriate. 

Sister Middleton meets with the nurse responsible and reassures her that she should feel confident to report any training needs. The nurse discloses that, although she has been fully trained in this area, she still feels uneasy from time to time. To support her, they agree that she would be supervised when inserting cannulas for peripheral IV access for an appropriate period of time.