Escalating concerns


Dr Wilson is a second year core medical trainee. He is the medical cover for the wards at a busy teaching hospital in Scotland.


Dr Wilson is bleeped to the respiratory ward to see Mrs Cullen, an elderly female patient with community acquired pneumonia at 8pm. He reviews Mrs Cullen and makes a management plan which he records in her medical notes. He informs Nurse Sutherland of the management plan, and asks her to give Mrs Cullen oxygen, fluids, antibiotics and hourly observations throughout the night. 

At 0130, Dr Wilson is fast bleeped to the respiratory ward where Mrs Cullen has become critically unwell. Nurse Ritchie, who recently started her shift, explains that she found Mrs Cullen to be dangerously short of breath, barely conscious and in a lot of discomfort. 

The Rapid Response team were called and Mrs Cullen was transferred to the critical care unit, where her condition is stabilised. Dr Wilson reviews the drug and observation charts and sees that Mrs Cullen did not receive hourly observations. 

What the doctor did

The following day, Dr Wilson asks Nurse Sutherland why Mrs Cullen was not given  hourly observations. He stresses the risk to Mrs Cullen, who could have died as her condition deteriorated very quickly. He reflects that Mrs Cullens daughter was distressed as she had witnessed the deterioration in her mother; she remained overnight in the bedside chair. 

Nurse Sutherland is shocked and upset. She explains that she misheard Dr Wilson and thought he said Mrs Cullen needed four hourly observations. As it had been a busy night shift she explains that she hadn't cross-checked the verbal instructions with those in the patient notes. She says that when she finished her shift, Mrs Cullen had been stable and she had verbally handed over her care to Nurse Ritchie. This further complicated the situation as Nurse Ritchie did not check the patient notes either.

Dr Wilson listens to Nurse Sutherland's explanation but he feels that though he can understand what had happened and why, the incident and the cause have serious implications for patient safety. He completes an incident form.

Dr Wilson approaches the Ward Manager, Mrs Baxter, and they agree it would be helpful if the Director of Quality Improvement did a Failure Modes and Effects Analysis (FMEA) of the handover to see what steps could be taken to avoid similar problems. 

The investigation finds that Mrs Cullen's notes had clear instructions from Dr Wilson. However, a culture of over reliance on verbal instructions for handover of patients' care had developed in the department during a long running period of staff shortages.

They introduce a new communication tool, the SBAR (situation, background, assessment, recommendation), to manage handovers and make sure there's a consistent approach to written and verbal instructions.