SCOTTISH AUDIT OF SURGICAL MORTALITY
Peer Review Feedback
Feedback is an essential component of any successful audit and occurs in the following ways:
Consultants automatically receive feedback
on their individual cases where adverse
factors in management have been identified. This may
take the form of a simple structured document listing the adverse events
or a more detailed textual report based on examination of the case
record |
|
|
All consultants and trainees receive anonymised, collated case
note assessments at intervals. | |
|
Hospital or Health Board reports are available on request | |
| .
An Annual Report is produced
to highlight important lessons | |
|
Individual Consultant SASM Report
for consultants, amalgamating their annual returns to help in
the identification of recurring problems in patient management. |
|
Examples of Individual Case Study
This assessment is carried out by an independent Consultant in the relevant speciality but in a different area and consists of a short history, a factual account of the clinical events, an assessment of the case and suggestions for improvement in management. It is important that these reports are taken in the spirit of being a peer review assessment and not a judgement of the quality of care delivered. Clinicians may disagree with these assessments but this is the true spirit of a peer review audit process.
Samples:
COLON/RECTUM
Inadequate resuscitation prior to emergency colonic surgery
This patient who was in his late seventies was admitted as an emergency with signs and symptoms consistent with a large bowel obstruction secondary to a descending colon carcinoma. He underwent a sub-total colectomy and formation of ileostomy and mucus fistula formation. The surgery was undertaken by a Consultant and the anaesthetic given by an SHO.
It is clear that there was little time lost in the determination of a definitive diagnosis and taking the patient to theatre for an urgent laparotomy. He was known to have carcinoma of the prostate without overt evidence of metastatic disease and apart from hypertension he had no other significant past medical history.
The time of his admission to the Ward is unclear, because this is not documented in his notes. After the initial clerking of the patient, there is no documentation as regards the results of the investigations listed, a plan of action and what resuscitative measures were to have been undertaken. Apart from the laparotomy note, the next entry into the notes is that of his cardiac arrest and certification of death.
It is clear that when this patient was admitted he was hypotensive, dehydrated and had severe biochemical disturbances with hypokalaemia and markedly elevated urea and creatinine. Although he had prostatic carcinoma his urea and electrolytes had been documented as being normal only four months before and therefore the resultant biochemical disturbance was probably a direct result of his acute presentation.
There do not appear to have been any ICU beds available either pre-operatively or post-operatively but pre-operative resuscitation should have been undertaken in this patient prior to theatre. It is not clear from the notes or records how much fluid resuscitation and correction of the biochemical disturbances were undertaken pre-operatively.
No criticism can be made of the surgical procedure or the level to which input was made at Consultant status. However, it is apparent that this elderly gentleman was inadequately resuscitated pre-operatively, lacked intra-operative monitoring such as a central venous line and the anaesthetic was carried out by an inexperienced anaesthetist. Had more appropriate preoperative resuscitation been carried out in association with more senior anaesthetic input, the risk of intra-operative myocardial infarction, which resulted in this patient's death, may have been significantly reduced.
|
|