64 Address where alleged harm occurred Cottage Hospital XX Town Details and date of the initial concern Copy details from concern form: Mr X reported that a nurse failed to give him his warfarin medication on the 12.07.2021. He raised this with the nurses the following morning who confirmed that the dose had been missed. They arranged for a blood test and the warfarin was restarted the evening of the 13.07.2021. Specific actions required of the nominated enquirer to be incorporated within section 2 of this report. Review nursing records and MARS charts for 12.07.2021 and 13.07.2021 Speak with staff on duty on the evening of the 12th and the morning of the 13th Complete NER form to detail findings Section 2 to be completed by the Nominated Enquirer Relevant background information about the adult at risk Including known factors such as services received, diagnosis, factors that either increase or decrease their risk of harm This should be included in the information given to the Nominated enquirer Mr X has given his consent for an enquiry to be undertaken into the missed dose of warfarin. He would like to ensure that this doesn’t happen again to other patients on the ward Chronology of events leading to the concerns Mr X admitted to the ward on 08.07.2021. He was transferred from an acute hospital following a hip replacement after a fall. Admitted to the ward, taking 10 mg of Warfarin daily, dose confirmed by INR blood test on 09.07.2021, 3 days prior to the missed dose. Mr X raised his concern with the morning staff who confirmed that it had not been signed for. 13.07.2021 INR blood test taken and new dose of warfarin prescribed and administered at usual time, 18.00 Information about the person(s) alleged to have caused the harm Mr X identified the nurse who missed the medication as female with long brown hair worn in a ponytail, Mr X cannot remember her name. How has this enquiry been undertaken? Nurse identified to be Flo. She can recall the shift as they had another patient who presented with challenging behaviour. The medication round was frequently disrupted by this. Flo cannot remember missing any medication. The MARS chart for the evening of the 12th showed a gap for the warfarin medication. Flo admits that she may have missed this tablet due to the disruption on the ward and her being constantly asked to help other staff. What are the findings of the enquiry? If any gaps or omissions in care/practice were identified, please give details.
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