1. Could it happen here Campaign Patient died of Clostridium difficile

2. Could it happen here campaign Why put patient safety first? Quality is: Patient safety, patient experience and clinical outcomes. The public expectation is that this is embedded and the norm not something additional. Care should include – assessment, prevention, treatment, education and communication delivered with compassion and empathy.

3. Could it happen here campaign What happened? Patient admitted to community hospital with falls, confusion, UTI and generally not coping at home. He received 4 courses of antibiotics during his 6 week stay. Patient received a daily medical review but there was no consultation with a microbiologist regarding treatment. High use of bank staff but all in date with IC training. The patient died and Clostridium difficile was stated as the main cause of death on his certificate.

4. Could it happen here campaign What did we learn? The patient was septic, but there was no proven microbiology results to confirm the diagnosis. Medical staff prescribed antibiotics but these were not discussed with the Consultant on call. This patient was at high risk of Clostridium difficile but a Microbiologist was not consulted for further advice. Prescriptions charts were not being monitored regularly Stool charts were not being commenced as soon as a patient developed diarrhoea of unknown cause Chlorine cleaning was not commenced until 2 days after the positive C diff result was known.

5. Could it happen here campaign What are we doing differently? For patients who are septic but there is no proven microbiology, the choice of antibiotic must be discussed with the Consultant on call. If these patients are at high risk of Clostridium difficile the Microbiologist should be contacted for further advice A pharmacist checks all prescriptions charts on a regular basis Stool charts are commenced immediately for all patients with unexplained diarrhoea Chlorine cleaning is commenced the day the positive result is known to prevent further spread of infection

6. Could it happen here campaign Discussion – 10mins Could it happen here? Has it happen to here? What was the effect to patient safety, patient experience and clinical outcome? Is it acceptable to your professional and organisation values?

7. Could it happen here campaign How do you prevent it happening? Discussion 10mins

8. Could it happen here campaign What have you learnt from this incident and will do differently to improve patient safety, patient experience and clinical outcome?