3: Missed AMI Dr Tony Kambourakis

Question You receive a phone call from the coroner that a patient seen in your ED subsequently died at home from an AMI. 35 year old man presented with epigastric pain He was seen & discharged by one of your junior registrars

3 hospital personnel to notify Director ED Chief Medical Officer / Clinical governance Risk management team Medicolegal team Operational executive NUM

Review notes List 5 important aspects of case that you wish to investigate Timeline of case Initial assessment Investigations & interpretation Assessment and differentials considered Supervision/consultations Disposition and follow up – including advice

Inform registrar involved List 4 points to cover during the conversation Registrar’s account Subsequent course – investigation, coronial process, open discussion Identify care management problems Identify any gaps in knowledge, training Action plan – supervision, training Provide support

Protocol development Identify need / current gaps Benchmark, literature search Stakeholder input Draft procedure Distribute for comment Final procedure Implementation and communication /education Evaluation – audit, feedback Refine

Breakdown Pass mark 12 / 20 Pass rate 74.3% Mean = 13.5 / 20

Thank you