Theme | Local reviews N=28 | External reviews N=33 |
---|---|---|
National guidelines or good practice points: | ||
Followed | 13 | 28 |
Not followed | 11 | 24 |
Senior review mentioned | ||
Consultant involvement noted | 14 | 28 |
Lack of consultant involvement | 7 | 12 |
Communication themes reported | ||
Good: | ||
with the patient and family | 2 | 19 |
between staff members | 4 | 14 |
Poor: | ||
with the patient and family | 3 | 9 |
between staff members | 4 | 11 |
Comments on documentation | ||
Some areas of good quality | 8 | 13 |
Some areas of poor quality | 10 | 29 |
Medication errors noted | 2 | 11 |
Individual supervisory action recommended | 4 | 0 |
Reported delays in: | ||
Diagnosis | 5 | 22 |
Obtaining a second opinion | 2 | 3 |
Providing treatment (excluding drugs) | 7 | 9 |
Administering drugs (eg, antibiotics) | 3 | 5 |
Requesting blood or clotting products | 0 | 2 |
Gaining access to blood or clotting products | 0 | 2 |
Transferring patients (eg, to theatre or the labour ward) | 2 | 6 |
Suggestions for alternative clinical approach made | 0 | 16 |
Note that several themes may have been identified for each woman, and therefore the total number of themes identified exceeds the actual number of cases examined.