Bedside nursing handover has been introduced at Whangarei Hospital following the death of a patient in 2010 that the Health and Disability Commissioner found was due to inadequate post-surgery care and poor communication.
The commissioner recently released his report into the death in 2010 of a 75-year-old man with complex co-morbidities following knee surgery at Whangarei Hospital.
He found that a combination of poor documentation and poor communication led to the failure of both the orthopaedic and nursing teams to recognise and act promptly on the man’s deteriorating condition.
“The failures of the orthopaedic and nursing teams were service failures and are directly attributable to Northland DHB,” says the Health and Disability Commissioner report, which found the DHB breached the health and disability services code.
The 75-year-old patient was a high-risk patient for total knee joint replacement (TKJR) because of his complex co-morbidities including diabetes, several serious heart conditions and moderate renal impairment. He was advised by an orthopaedic consultant that there was a significant risk he could die during or after surgery. But the patient had recovered well from prostate surgery in 2007 and he made the decision to proceed with the knee surgery.
The surgery proceeded without incident in February 2010 and the patient is recorded as doing well until day three when his urine output and blood pressure began to decrease. But failures in communication and documentation meant the catheter was still removed on the morning of day four and the orthopaedic and nursing team “failed to fully recognise” the patient’s deteriorating condition and on day six he suffered cardiac and respiratory arrest and sadly died. The report also noted that the afternoon nurse shift on day three was understaffed and that the nights between day three and five were “particularly busy” for medical staff.
The Health and Disability Commissioner report found that the orthopaedic team did not alert the nursing team to the patient’s complex co-morbidities and the need for close monitoring of him post-surgery.
He also found that the nursing team failed to alert the orthopaedic team to concerns about the patient’s urine output and that the team made a number of inaccurate calculations and recording errors on the fluid balance chart. And that members of both the nursing team and the orthopaedic team failed to read the patient’s notes and on occasion the clinical notes were incomplete and poor.
The Northland DHB said it “profoundly regrets” what happened in 2010 and accepted the care received was not of a high enough standard.
It says following internal inquiries it had introduced a number of corrective actions prior to the HDC report being completed.
These included that the nursing team now hand over care at the patient’s bedside at the beginning and end of each shift. There had also been inservice education on fluid balance charts and clinical handover including the planned introduction of the SBAR (Situation Background Assessment Recommendation) tool to ensure patient information, including fluid balance, was consistently covered in verbal handover process between nursing and medical staff.
All nurses and junior doctors working on the orthopaedic ward are now required to attend the ALERT course on recognising patient deterioration and a new clinical nurse educator was appointed to the ward in 2012.
Junior doctors have also been given extra time for handover and encouraged to contact their seniors for advice at any time.
The full HDC report can be read here.
