concerns the harm associated with failure to rapidly diagnose and treat spinal cord compression and poor handling of patients where it is suspected or diagnosed.
Examples of incident reports:
Admitted following fall… leg weakness…urgent MRI total spine requested…performed 5 days later. Verbal report no cord compression. Scan did not include upper thoracic spine as requested. Pt became paraplegic. Thoracic MRI confirmed cord compression.
Pt handed over - no observations ? completed by ambulance crew..no immobilization, pt sat up at 45 degree angle with new numbness to both legs following a fall with previous spinal injury.
Compression of the spinal cord can occur as a result of trauma or disease. In all cases it is regarded as a medical emergency and prompt diagnosis, treatment and careful handling is required to limit disability resulting from irreversible spinal cord injury.
In 2008, NICE
issued guidance on the recognition, rapid assessment and treatment of metastatic spinal cord compression, this includes having a clear pathway for diagnosis and treatment, local access to urgent MRI within 24 hours and informing high risk patients of symptoms and access to help.
Following a serious incident and a letter of concern from a GP cancer lead, 334 relevant incident reports were identified in the National Reporting and Learning System (NRLS). There were two reports of patient death, 33 severe harm and 60 moderate harm. Delayed diagnosis or treatment was identified in 193 cases and poor handling was identified in 30 cases. In 25 cases there was difficulty in the identification of the team responsible for the management of the patient.
For patients with cancer there were also transport issues in relation to radiotherapy treatment at a different hospital and 43 of these incidents occurred following the publication of the NICE guidance.
Organisations may wish to consider their pathways for patients presenting with symptoms of spinal cord compression and the training of staff in the rapid assessment and handling of such patients.
Please contact us
with your initiatives to reduce risk in these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.