1. 3: Missed AMI
Dr Tony Kambourakis

2. 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. 3 hospital personnel to notify
Director ED
Chief Medical Officer / Clinical governance
Risk management team
Medicolegal team
Operational executive
NUM

4. 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

5. 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

6. 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

7. Breakdown
Pass mark 12 / 20
Pass rate 74.3%
Mean = / 20

8. Thank you