As a Junior Doctor, you may be called to attend to patients who have experienced adverse incidents during their hospital stay. Handling such situations requires prompt action, effective communication with Nursing Staff, and thorough documentation. In this blog post, we will discuss the essential steps to follow when faced with an adverse incident, emphasising the importance of clear communication, thorough assessments, and proper documentation.

Responding to an Adverse Incident

When called to see a patient who has experienced an adverse incident, it is crucial to act swiftly and work together with the Nursing Staff. Keep the following in mind:

• Prioritise seeing the patient as soon as possible. Nurses have a legal obligation to ensure that you see the patient promptly. Be understanding and respectful of their concerns, even if you are busy (which often you will be!).

• Gather information about the incident by speaking with the patient, nurses, and any witnesses present. Conduct an initial emergency assessment using the ABC approach.

• Perform routine observations, including temperature, blood pressure, pulse, oxygen saturations, and respiratory rate and record the patient’s NEWS score. Assess the patient's level of consciousness by assessing their Glasgow Coma Score (GCS). Note that unequal pupils should be evaluated in the broader context of the patient's overall condition.

• Conduct a brief neurological examination, including an assessment of cranial nerves and plantar reflexes.

• Examine the patient for signs of bruising, bleeding, cuts, or fractures. If the patient complains of new pain as a result of trauma from the fall, then it’s best to be cautious and request imaging (e.g. X-Ray) to rule out any possible fractures.

• Document your findings, ensuring clarity and accuracy, in the patient's notes.

Completion of Incident Forms

To ensure proper reporting and accountability, it is essential to complete incident forms (i.e. a Datix). The actual form itself will often be completed by Nursing Staff but there are some things you you need to remember - follow these steps:

• Nurses will provide you with an incident form, which you must sign and fill out. If your hospital uses an online system for incident reporting, you may not need to complete a physical form (which is often the case) unless you have additional information or specific concerns to convey.

• Additionally, write a summary of the incident in the patient's notes. Include your name, designation, time, and date.

• Provide a brief history of the accident, including any information obtained from witnesses or the nursing staff.

• Clearly document your examination findings, paying attention to the ABC approach. This facilitates easy identification of any changes in the patient's condition.

• Outline a plan of action, indicating that you should be contacted immediately if the patient's vital signs deteriorate or if there are any concerns.

• Note that the incident form has been completed by the nursing staff.

Ongoing Neurological Observations

To monitor the patient's condition, request that nurses perform regular neurological observations. Consider the following:

• Specify the frequency at which you require neurological observations, including calculating the patient's GCS, assessing pupil reactions, and monitoring limb movements - refer to local Trust guidelines on how often these observations should be performed.

• Neurological observations are usually indicated for:

  • Those with a suspected or confirmed neurological condition including Cerebral Vascular Accident (CVA/Stroke), ICH, SAH etc.

  • Those presenting to hospital after sustaining a head injury.

  • Those who are acutely unwell due to an unknown cause.

  • Those who have an unexplained reduced level of consciousness

  • Those post first seizure

  • Post thrombolysis /thrombectomy (Stroke patients only)

  • Those who sustain a head injury whilst in hospital.

  • Following a fall that has resulted in head trauma/injury.

  • Those who sustain a head injury by any other means whilst an inpatient.

  • Post Neurosurgery

• Frequency of Neurological Observations will depend on how acutely unwell the patient is as well as the cause of their deterioration. Typically the frequency of neurological observations will take the following structure as listed below (according to a 24hr day).

• Neuro. obs should be performed:

  • every 30 mins in first 2hrs

  • every 60mins in next 4hrs

  • every 120mins in the following 6hrs

  • every 4hrs for the remaining 12hrs

  • However, the frequency of observations can change according to the situation - so always assess each patient on a case-by-case basis. If unsure or in doubt, speak with one of your SHOs or Registrars for further help and guidance.

• Balance your requests with reasonability, being mindful not to overburden the nursing staff. However, if you have genuine concerns, assert the necessary frequency to ensure patient safety.

• Remain responsible for the patient's well-being, making sure appropriate observations are conducted.

Reflection and Referral

Take time to reflect on how the incident occurred and consider if further action is required - if so then perform an relevant investigations and refer the patient promptly.

This is also an opportunity to consider adding this incident to your portfolio in the form of a learning event that you have reflected on.

Conclusion

When confronted with adverse incidents, effective communication, comprehensive assessments, and accurate documentation are vital for patient care and legal accountability. By following the outlined steps and maintaining a collaborative approach with the nursing staff, you can ensure a prompt and appropriate response to adverse incidents. Remember, patient safety is paramount, and your dedication to thorough incident management contributes to providing optimal healthcare.

by Dr Ahmed Kazie