Incident

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February 2014 - case study 2

Date: 01 February 2014

  • Details:

    A patient with heart failure and receiving regular care from nurses in the community developed breathing problems and an ambulance was called. A Paramedic attended and determined that the patient was safe to remain at home and to wait for the next scheduled nurse visit for antibiotics to be prescribed. The patient’s family were unclear about the assessment performed on the patient and the care pathway recommended by the Paramedic. They also felt that the Paramedic made a decision about care and then changed her mind after reading the notes.

  • Findings:

    The investigation found that the Paramedic made a decision to call for an ambulance to transport the patient to hospital, but then decided that waiting for the scheduled nurse visit would be appropriate after reading the patient’s notes. The information communicated to the patient and her family regarding the series of assessments being performed was not effective.

  • Lesson learnt / action taken:

    The paramedic was given the opportunity to reflect on the care provided and support was given regarding the importance of obtaining a complete history before making a treatment decision. The importance of communicating clearly with the patient (and any family members present if relevant and permission has been obtained from the patient) regarding the assessments being performed and the treatment decisions being taken was emphasised.

  • Date:
    01 February 2014