A patient developed signs of sepsis in the post anaesthesia care unit following emergency surgery. Hypotension was resistant to fluid challenges. Post operative instructions were to continue antibiotics; however, the electronic prescribing and medicine administration record contained no details of previous doses given. There was a delay trying to obtain this information from the surgical and anaesthetic teams and it is unclear where this information was recorded. The patient was transferred to critical care.

Commentary

Some electronic prescribing and medicines administration recording systems automatically pull data from the [electronic] anaesthetic chart and will calculate times of subsequent doses. When this is not the case non-anaesthetic staff can find it difficult to access the anaesthetic chart for this information. There should be a local protocol determining who is responsible for postoperative prescribing and how and where this is done. Standardisation of the handover process between different teams and departments has been shown to reduce errors.¹

1. Blazin LJ, Sitthi-Amorn J, Hoffman JM, Burlison JD. Improving Patient Handoffs and Transitions through Adaptation and Implementation of I-PASS Across Multiple Handoff Settings. Pediatr Qual Saf. 2020 Aug;5(4):e323.