Health has issued its preliminary report on Daniel affair online, and ask for feedback before it is completed. Professor Olav Røise has Aftenposten request carefully studying the Board of Health’s assessment of whether Daniel received proper treatment – to see if it is possible to learn from what happened when Daniel (2) died at Molde Hospital in 2009.
Røise has extensive experience in emergency medicine who hurt surgeon, but also as a clinician. He has extensive experience as a manager and director at various levels and has worked extensively with learning to improve patient safety.
Røise roses Health for openness they have shown in Daniel case, however, questions are asked by the Board of Health review of treatment Daniel received.
Good enough supervision?
But he poses several questions in the review of Health: Daniel got proper surveillance, and the organization of the surgical team was optimal.
Daniel lay to monitoring in the hospital because he had started to bleed after a tonsil operation. When he started bleeding again, it was decided reoperation. It is during this operation that Daniel did not get enough oxygen and suffered brain damage.
– Daniel probably had a bleeding over time, including one found coagulated blood. So it was hardly an acute controlled bleeding that was the direct cause of Daniel suddenly became very poor, says Røise.
Large blood loss
This, together with the children physiological “compensate” by haemorrhage (blood vessels are contracted, pulse counting) means that children have normal blood pressure – despite major blood loss. But only up to a point, according Røise.
– The body can at this point no longer to compensate, and the patient goes quickly into what we call hemorrhagic shock. When it’s all about fast and effective treatment – for establishing blood volume
Followed wrong parameters?
Røise is critical to the nurses, who watched Daniel in this situation, was instructed to follow with the appropriate parameters, before it was the need for emergency surgery. Should Daniel have been on surveillance anymore?
– This is obvious questions, but Health set them, he said.
He says it all the more complicated that what usually shows blood volume – blood percentage – in such a situation, do not provide enough information.
The nurses can not be
The report concluded that the patient was well monitored by nurses.
– The information available does not suggest that. Consequently, it may also be a learning point, not only for Molde Hospital, but for all Norwegian hospital.
Røise strongly emphasizes that nurses can not be blamed for this.
– My point is that this can be a very important learning point, not only for Molde Hospital, but for all Norwegian hospital.
Inadequate interaction?
Røise also believes that the interaction during surgery is a critical point. It is right to question whether the outcome could have been another if the team had acted in a different way.
– These are difficult questions, but they must be set by a regulator, says Røise.
– It appears that some meant they worked steadily, while the surgeon – who arrived late in the course – described the situation as chaotic. The report further discloses that the connection to common overvåknigsutstyr which one is completely dependent on in critical situations, was not done. Common procedures with securing breathing tube was not done, and the report discussing whether this was perhaps the reason why the patient is not charged with oxygen.
Chaotic in the operating room
– For me what is described here a situation that fits better with the surgeon described in his medical record – as chaotic, says Røise.
He does not question whether each doctor or nurse did her optimal, but about the assumptions they had was optimal. Could the hospital have organized themselves and therapists in a better way, for such rare and critical situations?
The surgeon is not part of the initial team
He justifies this objection with the team, after all, got life in Daniel again, but then after a prolonged circulatory arrest.
– Based on the report it seems reasonably certain that it is because a surgeon present guard was eventually summoned (32 minutes after the operation was decided), and promptly got put a needle right in the bone marrow in the fibula of the patient. This meant that Daniel was applied blood, fluids and medications. This is a procedure used in the treatment of severely injured children and that is part of what is taught in a required course for surgeons and anesthesiologists in Norway.
– There is every reason to ask whether the surgeon should Having been part of the team from the start. Then that person would probably have done this with the same, and the situation could have been more manageable, says Røise.
Missing expertise?
He also says that there are several other issues he is surprised that the Board of Health does not go into, or questioning.
– The reason may be lack of competence or clinical experience in investigation unit on the ones here to investigate. If communities of Health examines not characterized by openness, it needs special expertise in precisely what they will examine, in contrast to what is required in a busy environment of learning itself. I do not know whether they have used new experts, but doubt it, since it is not lighted.
Røise will submit a supplementary note to the Board of Health about what he Aftenposten card here has explained.
Health: -All should be reviewed
– We want the health service to learn from their experience, what we ourselves must do well, writes director Jan Fredrik Andresen in Norwegian Board of Health.
– What we see through the large notice our cases, is that it is important to get close to the event in terms of both time and place. We must ensure that those involved actively participate in our surveys. Therefore, the transformation of the warning system, so that supervisors receive information about the serious incidents in the past, important. Such was not enroll scheme when Daniel died. Although we must become even better at presenting events and causal relationships, so that those who have been involved recognize. Furthermore, we must attach great importance to marvel us when we are not sure, and we must be responsive to questions and suggestions from outside.
Meetings Aftenposten sources
– In connection with Daniel- case has been invited by those who have criticized us in Aftenposten articles, to meet us, so we can hear more detail about what they mean.
We have also challenges related to convey its mandate our and our role and what our conclusions actually means and means.
He concludes that “all documentation and information should be thoroughly reviewed and assessed by case managers with the correct competences” and informs that the Board of Health, before the report is completed will have new talks with Daniels parents. All involved are also given the opportunity to express their views.
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