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criteria 4. Significant events analysis

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  2. Significant Event Analysis
    Title: Lost ECG before scanned to computer or seen by GP
    Date of significant event: 20/03/2009
    Date of significant event meeting: 1/04/2009
    Date report compiled: 1/04/2009
    What happened?
    Health care assistant did a routine ECG for one of the patients. The health care assistant put it on the on-call doctor tray assuming that the on-call doctor will pick it up. I was the on-call doctor that I didn’t see or comment on the ECG.
    Why did it happen?
    Several notes came out of this event, firstly poor communication.
    Secondly it showed a faulty system in reviewing ECGs in the practice.
    Who was involved in the discussion of the event?
    Health care assistant, practice manager, myself, and the senior partner.
    What have you learned?
    1. More clear instructions to staff
    2. More clear explanations of procedures to patients and what to expect
    3. Better communications between the staff and doctors in the practice
    What have you changed in the practice as a result of the review?
    Routine ECG performance protocol:
    1. GP order ECG and mark as routine on entry, and make patient aware
    2. nurse/ or health care assistant do the ECG
    3. it is the responsibility of the one who done the ECG is to show it to the on-call ( duty ) doctor
    4.Nursing staff to put on on-call doctor’s screen a slot for reviewing ECGs if more than one
    5. Patient shouldn’t go home unless ECG is seen and patient is reviewed by duty doctor if needed.
    That was discussed and all the GPs and nursing staff agreed about is on our clinical meeting session
    What have you changed in your personal practice as a result of the review?
    This event wasn’t much related to my practice; however I learned that when ordering a routine ECG I inform the patient about the usual procedures the practice take to have this investigation done.

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