The clinicians view
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We think about patients, not populations Reviewing from a population view is about what happened Reviewing from a patient view is about what should have happened Hindsight bias Poor care bias – even if it made no difference. The Clinicians’ View.

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Presentation Transcript
The clinicians view

We think about patients, not populations

Reviewing from a population view is about what happened

Reviewing from a patient view is about what should have happened

Hindsight bias

Poor care bias – even if it made no difference

The Clinicians’ View


Most cases are fairly easy to score and in south tees most are a hogan grade 1 or 2

Most cases are fairly easy to scoreand in South Tees most are a Hogan grade 1 or 2




The clinicians view

  • Aet 97

  • Care Home Resident

  • Mild CFF due to IHD

  • PPM


The clinicians view

  • Right sided weakness

  • Partial Anterior Circulation Stroke

  • Probably during night - found 0730

  • CT at 0900

  • Thrombolysis at 0944 - alteplase - direct consultant supervision

  • On stroke ward by about 1030

  • Next day alert, sitting out, but aphasic


The clinicians view

  • Good all round care

  • Some notes unclear or difficult to read

  • SALT done early

  • Good rehab

  • MDT plans by day 14 for placement


The clinicians view


The clinicians view


The clinicians view



The clinicians view

  • Aet 71

  • Known AAA under surveillance

  • IHD

  • PVD


The clinicians view

  • GP referral

  • Known AAA - 5.1 cm

  • Midline pain spreading through to back

  • A&E ? Leaking AAA


The clinicians view

  • A&E noted AAA

  • CT aorta within 30 minutes of arrival. Not leaking but now 5.9cm

  • ? Renal colic, ? Diverticulitis

  • Admit surgeons

  • Discuss with vascular

  • Imaging shows no stone and no clear diverticulitis


The clinicians view

  • Day 3 "pain over AAA ++"

  • Refer vascular

  • Seen later on, less tender, but pain is postural and radiates to back

  • MDT Friday


The clinicians view


The clinicians view


The clinicians view

  • There were odd features in the presentation

  • But he wasn’t re-imaged and he doesn’t seem to have any high level reviews that actively questioned the putative trivial diagnoses

  • Our urgent AAA results mean his risk of death with surgery was very low



The clinicians view


The clinicians view


The clinicians view

  • AF speeds up and BP falls

  • Nothing else obviously wrong

  • Med Reg gives advice on the ‘phone

  • More metoprolol

  • Immediate terminal decline

  • Bloods come back too late - Hb 6


The clinicians view

  • The bleeding was not obvious

  • AF speeding up is common in these circumstances

  • Catastrophic bleeding is rare

  • So in the original team’s shoes…