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Louis Tate death (Event Sequence (13 yo boy, PHx: asthma allergy to cows…
Louis Tate death
Event Sequence
13 yo boy
PHx:
asthma
allergy to cows milk, raw egg
peanuts, tree nuts
Admitted to hospital with acute asthma attack
Observed overnight
Reviewed by night reg at 07:00 - safe for discharge
Deterioration soon after breakfast
Dies despite medical management
Workplace
Workplace factors
Handover time
pressure on beds
Equipment Design
Monitoring
warning systems
Work Environmen
Noise
Visibility
Competing demands
Parent / healthcare professional communication
Mo tells nurse about:
food allergies
epipen in bag by bed
what should be ordered for breakfast
System
Supervision
No double checking of food being given to pts with allergies by nursing staff
Escalation process
Management of allergies
Clear documentation on drug chart / notes
Clear documentation on door or bed
No double checking of food being given to pt with second person (Mo or nurse)
Child less reliable to alert PSA to allergy
Child less able to discern if food delivered is appropriate
Food handling systems around handling of food allergies
Aliquoting vs individual sealed serves of food products
No system where pts with allergies visible / recorded in kitchen area
No method where allergies are recorded on food tray being prepared
Ingredients of content of food on tray not readily visible to nurse, PSA or pt families
Mangement
Organisational Factors
resourcing
organisation of work
procedures/guidelines
leadership
Job Design
workload
rosters
task design
supervision
Informational transfeer
communication
Mo tells nurse info
Nurse records info in patients notes
doctors rarely read nursing notes
QUERY: was allergy alerts filled in?
handover
People
Individual Factors
Knowledge
Health professionals insufficiently trained in management of anaphylaxis
Health professionals do not recognise seriousness of the situation
Expectations
patient will improve
Physical conditions
Unknown
Culture
Senior staff take hands off approach
workload
Unknown
Competency
Health professionals unable to put knowledge into effective practice
Fatigue
Night registrar leading resuscitation
Attention
Cognitive bias - Asthma
Team Factors
Mo leaves ward at 01:45am to go home & sleep