Table 3 NOTTS as a cause of death in surgical patients
Domain | Frequency(n, %) N = 112 | Example |
|---|---|---|
Situational awareness | 58(51.8) | “Patient returned from theatre after NOF repair at 12.45. Vital signs at 14.15 show hypotension (seagull sign). No further observations recorded. At 14.30, nursing notes state the patient has not passed urine. Examination of the fluid balance chart suggests the patient has not passed urine at all that day. Did he in theatre? Not according to the anaesthetic chart. Fluid prescription chart shows 5 bags of fluid given not reflected on fluid balance chart[sic]” |
Communication and teamwork | 23(20.5) | “Patients conditions deteriorated at 1700 Dr P [staffname] informed. He attended to patient and tried to contact the orthopaedics team which he tried for four hours then to find he was not on call and was on holiday abroad. Patient’s condition deteriorated further. An anaesthetist was contact and saw patient.” |
Leadership | 18(16.1) | “Patient admitted with trauma to his right lower leg was administered anti-hypertensives and other medication prescribed for another patient. The patient’s condition deteriorated 6 hours later requiring transfer to critical care where he subsequently died approximately 38 hours following the medication error. No leadership on orthopaedics ward [sic]” |
Decision-making | 13(11.6) | “admitted for NOF repair, unwell from A& E, should have had 3 litres of fluid and 2 units of blood overnight with repeated ABGs at 4 pm. Overnight apparently unrecordable BP but no medical opinion was sought. 7 am ABGs done by HO. Condition worsening-attention then brought for low BP. SPR unsure [about] coming to ward…because of severity of illness and staffing levels. SPR called and central line inserted and IV fluids given. Patient died at 13.00 hrs RIP [sic]” |