Handover gap on a busy ward round
You are the night registrar covering two wards. At 02:00 you are called about a 76-year-old woman, day 3 after hip fracture surgery, who is confused and agitated. The day team's handover sheet lists her as 'stable, for discharge planning'. Nursing staff report she has become increasingly drowsy and combative over 4 hours; her respiratory rate is 26/min, SpO2 89% on room air, temperature 38.4 C, and she has not passed urine for 8 hours. There is no documented fluid balance or delirium screen. You are also covering a deteriorating patient on the other ward and cannot be in two places at once.
1. Prioritise your actions and explain the reasoning behind the order.
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Immediate priorities (in order):
- Recognise the emergency: This is a deteriorating post-operative patient with hypoxia, fever, tachypnoea and oliguria - likely sepsis (e.g. pneumonia, urinary tract infection, wound infection) plus possible delirium. This is time-critical.
- Delegate safely: Ask the ward nurse to start oxygen and continuous monitoring, obtain a full set of observations, and call the critical care outreach team immediately while you attend the other patient.
- Attend as soon as possible: Reassess personally, take cultures, start sepsis bundle (fluids, antibiotics per protocol), catheterise for urine output, and document a clear plan.
- Escalate: Inform the on-call consultant and consider higher-level care.
Reasoning: Sepsis and hypoxia are time-dependent; the initial minutes can be managed by trained nursing staff with outreach support, allowing you to triage both patients safely rather than abandoning either.
2. What system failures does this case reveal, and what would you do to address them?
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Failures:
- Inadequate handover - 'stable' did not reflect risk or the absence of monitoring.
- No delirium screening or fluid balance documentation.
- No early warning score escalation despite abnormal observations.
- Lone registrar covering two wards with no clear escalation pathway.
Actions:
- Complete an incident report (datix/equivalent).
- At handover, use a structured tool (e.g. SBAR) and explicitly flag at-risk post-operative patients.
- Reinforce use of early warning scores and mandatory delirium/fluid balance monitoring.
- Raise staffing and escalation concerns through governance channels.
- Share learning at departmental meeting.
This addresses both the individual patient and the latent system conditions that allowed deterioration to go unrecognised.