This ‘Signal’ is about the risk of inadequate pain relief and delays in care for patients with sickle cell crisis.
Extract from incident reported to the RLS:
“At approx 11.50hrs patient arrived from A&E… neither patient controlled analgesia (PCA) pump nor the amount of morphine required available on the ward. Site Manager had to then spend time sourcing the morphine and ward staff spent time sourcing PCA pump. During this time patient with sickle cell crisis went without his pain relief as only other pain relief prescribed was diamorphine - of which we have a very small amount - not enough for prescribed dose.”
The report of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) in May 2008, A sickle crisis, made recommendations to improve the care of patients presenting to emergency care with a sickle cell crisis. It identified issues such as the lack of trained haematologists to assess patients in A&E and inadequate pain relief for patients with sickle cell crisis.
A review of Reporting and Learning System (RLS) data showed little change in reporting rates over the two years since the release of the NCEPOD report, with around 50 relevant incidents each year.
Problems in providing adequate and timely pain relief were the most commonly reported issue (including lack of pain control analgesia (PCA) pumps on general wards), followed by delays in instituting a package of care, including one where delay led to an ITU admission and one where a child had a critically low Hb before transfusion was given.
We recommend NHS organisations revisit A sickle crisis and ask themselves if they could do more to implement its recommendations.
We would like to hear from you – please contact us or with anonymised copies of local investigations or information about your initiatives to reduce risks in any of these areas.
Signals are notifications of key risks emerging from review of serious incidents reported and shared by the NRLS.
Relevant to: medicine, emergency medicine
Short Survey on the value and effectiveness of Signals
This is a pilot project. To assess the value and effectiveness of Signals, we would be grateful if you and your staff could take a few minutes to answer a short survey. We would like to know if you have found Signals useful and how it could be developed further to suit your needs.