Item 24
Checklist & SBAR for Decision Making in Commissioning a
Significant Adverse Event Review
SAER Reporting and Decision Form
Date escalated to Executive Sponsors (Board Nurse Any
Director/Medical Director (Operational Division)
(OD):
Patient Name: A
Directorate:
CHI Number: 123
Service:
Incident Date: Any
Datix Ref
Number:
WEB13099
Severity of
EXTREME
Harm/
Consequence MODERATE
Rating:
Time: 2200
PLANNED
Speciality:
ORTHOPAEDICS
Location:
WARD 10
Organisation:
ACUTE SERVICES
Operational Division /
CHP/ other
SBAR Communication
Situation PATIENT IN Dept B REQUIRED TRANSFER TO CORONARY CARE UNIT
POST OPERATIVELY DAY I (EVENING) WITH MYOCARDIAL INFARCTION.
Background
ELECTIVE ORTHOPAEDIC ADMISSION FOR LEFT TOTAL HIP ARTHROPLASTY. PMH OF RIGHT
TOTAL HIP ARTHROPLASTY, ISCHAEMIC HEART DISEASE, HYPERTENSION, ANGINA AND
INSULIN CONTROLLED DIABETES. ATTENDED FOR PREASSESSMENT ON 9/7/13,
PREASSESSMENT NURSE DISCUSSED PATIENT WITH CARDIOLOGIST AND ANAESTHETIST,
HAPPY TO GO AHEAD WITH SURGERY AS PLANNED.
Assessment B - On admission blood sugar recorded as 9.3 MMOL.
C-Post operatively -FEWS 3 on return to ward due to low temperature and hypertension, IVI in situ, O2
therapy in situ, PAIN SCORE 6 using pca as required. BM 11.6, Dr informed staff to monitor meantime.
BM rechecked at 1735 noted to be 12.7 MMOLS. Insulin 72 units administered. Frusemide 40MG given as
kardex. FEWS 1 at 1800. 4 hourly BM stable and FEWS 0 overnight.
D - FEWS 1 at 0900 hrs, BM 14.2. Dr was asked to review patient as she was quite drowsy and had been
unable to give details to staff when dispensing analgesia at 0600. Routine day 1 bloods obtained, results
phoned to ward at 1110, showing potassium 7.3, HB 100. Medical instructions were to observe, stop
oxycontin, commence IVI and commence salbutamol nebulisers. Routine mobilisation commenced with
ward physio, but was incontinent of urine on route. Vague when in toilet, assistance given back to bed.
C/O visual impairment, inability to grip zimmer. Assessed by ward doctor, all observations within normal
limits-FEWS 0. BM 14.7-38 units of insulin given. Now uncomplaining of visual disturbance and gripping
without any issues. Nebulisers given at this point. Asked to catheterise to monitor output. 2015 hrs,
patient settled, BM 7.5 and insulin withheld. O2 saturations low on nasal oxygen therefore commenced
on 4 litres via mask. Light diet and fluids tolerated this pm.
Patient moved to bay 3 for closer monitoring where an epidural patient was being monitored 1:1
Night staff came on duty at 2100 hrs and at 2130, staff found patient agitated, unable to form proper
sentences together- patient aware of this. C/O numbness in both arms, although able to move both arms,
checked motor responses in both arms-able to move and squeeze both hands. Oxygen saturations on air
65-70%, lying flat in bed. Position adjusted, 5 litres of oxygen via mask- now 93%-FEWS 1. BM 11.3.
H@N contacted and asked to review. ECG and FBC, U&E’s, magnesium and calcium levels requested
which were carried out by nursing staff. Ward notified at 2233 Potassium level 6.7 at this time. Patient
transferred to Coronary care unit at 0310 hrs
Yes
No
N/A
The event is on the organisation’s list of distinct adverse events
X
that must always be submitted for review
The adverse event has attracted a consequence rating of ‘Major’ X
Item 24
or Extreme’
There has been an unexpected death
X
There has been significant harm - either physical or emotional
X
Please state brief detail re nature of harm/injury
PATIENT REQUIRED TRANSFER TO CORONARY CARE
UNIT FOR FURTHER MEDICAL INTERVENTION
The event required intervention required to save life.
X
There is a potential wider impact which may result in harm to a
significant number of patients
Environmental events that have caused death, significant harm
or required intervention to save life
Events that cause significant (major or extreme ) organisational /
other impact e.g.
X
Other events
X
Advice has been sought from the Employee Director and Head of
Occupational Health and Safety. Record details of all
communications
X
The event requires that an external agency be notified, such as
the Health and Safety Executive
X
X
X
Recommendation
e.g. Rapid Event Investigation (REI), Falls Rapid Event Investigation (Falls REI), Significant Adverse
Event Review SAER), Other
xxxxxxxxx TO ADVISE
Any
Completed By:
Dr X
Date:
A significant adverse event relates to NHS X’s list of distinct reportable events and/or all adverse events
attracting a consequence score of ‘Major’ or ‘Extreme’.
The rationale to initiate an SAER is based on best practice and focuses on the three priority elements of
unexpected death, significant harm (harm includes negative physical and emotional impact to e.g. a patient and
family) organisation or which may have required intervention to save life.
Distribution Checklist
Please forward completed SBAR to:
Divisional General Manager/CHP General Manager for Review
DGM/GM Please forward completed SBAR to
x
xx
Date
Any
xxxx
Item 24
PART 2 – SBAR DECISION
Executive Director completing:
X
Date:
Rationale for decision
Yes
Any
No
See below
Does the Executive Sponsor agree with the CHP General Manager/ Divisional
General Manager’s recommendations?
NA
Rationale for progressing to SAER
Rationale for not progressing to SAER




No clear suggestion above that significant clinical harm has been caused due to substandard
care
More information required – ie, in concise terms, what is thought to have been the issue
A local investigation (REI or SBAR – will take advice on which is most appropriate) will be the
most useful/appropriate course
If there is has been substandard care then an educational/learning approach will be the best
course
For further action
 By Directorate / Service

Yes
No
Other
DISTRIBUTION CHECKLIST
xxxx
xx
DATE
xx
xx
Item 24
Date SBAR Part 2 received by Risk Management Team
Date Added to Datix Incident Record
xx
Item 24
PART 3 – INITATING SAER
Timeline of Significant Adverse Event
Timeline
Due Date
Actioned
Yes/No
Incident Date
Immediate Checklist Received
SBAR Report Received
Decision of SAER Review
Initial Pre Log Meeting to agree Roles and Responsibilities of Review
Team
Inform Directorate/Service of SAER Decision
2nd REI Falls Investigation and RCA Methodology to be completed by
Arrange to meet/liaise with family/carer to agree expectations
Pre SAER Meeting to discuss Local Investigation and RCA
Full SAER Review Meeting
Development of Action Plan by Directorate
Date/s of LOG and SAER Meetings
Initial LOG Meeting
Pre SAER Meeting
Full Review Meeting –
Nominated staff are
required to attend
Review Team
Name
SAER Title
email
DM/GM to Nominate Key Staff to take part in the SAER Review (DM/GM to Please Complete)
Please staff must be released from duties to attend.
Staff Name
Job Title
email
DM/GM to Nominate Family/Carer Contact Person (if not Lead Reviewer) (DM/GM to Please Complete)
Name
Contact Details
DISTRIBUTION CHECKLIST
DM/GM to forward SBAR on completion of part 3 to
xxxxxxxxxxxx
Date SBAR Part 3 received by Risk Management Team
Date Added to Datix Incident Record
DATE
Item 24
Datix Response
Mrs xxxxxxx
High risk patient, known DM, known cardiac disease, chronic kidney disease, K borderline hyperkalaemic
Risks clearly discussed with the patient.
Patient seen in Preassess by xxxxxxx, who recommended a cardiac review.
Subsequently patient was admitted to AMAU and CCU 2x in June for cardiac failure
See by xxxxxxx subsequently and considered fit for surgery
Uncomplicated surgery
Seen the morning post op (day 1), noted to be a bit flat, blood were shown patient was hyperkalaemic with high BMs
Commenced on salbutamol inhalers and given insulin...xxxx indicates her BMs improved and her FEWS settled when he left at 1830 (?). No
repeat K was taken.
seen by HAN and noted to have a raised troponin and K elevated (although better than in the am).
Transferred to CCU...K still high, renal function returned to baseline. Cardiac event likely.
Reflection
1) this patient already pretty frail and at risk of cardiac event in view of recent history of heart failure, although deemed fit to proceed by
Cardiology
2) Patient probably warranted an HDU bed (may be worth suggesting this is added into the pre -op briefing to ask the question if anyone
is likely to require and HDU bed)
3) Patient should have had U&Es check later that day, however if the FEWS were 0-2 and the K was falling it is likely management would
continue along the line of diabetic control and salbutamol meds
4) With the initial high K, patient should have had an earlier medical review
5) I was not actually aware the patient had been admitted between preassess and her surg until after the op.....it may be worth introducing a
question at the initial nursing admission of "Have you been admitted or treated in Hospital since your preassessment visit". If I had
known this fact I would have postponed the surgery irrespective of the cardiac opinion.