cardiac arrest. interventions Investigate ways of Developed training plan improving clinical that: Limited organisational leadership at-scene. reviews of whether incorporates current techniques are Develop a policy for the leadership and high still best practice. regular review of how risk / low occurrence clinical interventions are interventions for performed. intensive care paramedics Develop guidelines on how to perform patient includes simulation care clinical sessions to support interventions. clinicians in application of these Investigate adding skills. intraosseous access to the paramedic scope of Reviewed operational practice. structure that will better support clinical leadership / performance of teams. Transport Provider Summary of event Root causes Recommendations Actions taken St John No members were Reliance on using Introduce requirement The bariatric ambulance available to retrieve a patient transfer service that specialist bariatric is expected in 0994SJA2015 specialist (bariatric) (PTS) staff to retrieve ambulance be crewed 2017. ambulance, which the specialist 21 hours a day. The powerlift stretcher is resulted in a prolonged ambulance. Introduce powerlift operational and crewed scene time and delayed stretchers that have a 24 hours a day, 7 days a transport for a patient higher weight capacity. week. with urgent needs. Develop policy and Training has been standard operating provided to PTS staff in procedure for bariatric the use of patient transfers. manual handling devices. Policy has been written. Technology Provider Summary of event Root causes Recommendations Actions St John Software failure delayed No further investigation Nil. Software was upgraded, an incident entering the was able to be which addresses this 1828SJA2015 dispatch conducted. type of failure. Communications centres Provider Summary of event Root causes Recommendations Actions taken St John Possible delayed Unable to conclusively Not applicable. Not applicable. response of crew to determine the root 0992SJA2015 helipad so helicopter cause due to loss of could respond to motor activity log data during vehicle crash. upgrade of computer aided dispatch (CAD) system. St John The closest available The dispatcher did not Dispatcher to review of Review enacted. resource was not use the review or revise the respond, review and 1020SJA2015 responded to a red the incidents, as per the revise methodology. (potentially life review and ‘respond, threatening or time revise’ methodology. critical) incident. The computer aided dispatch (CAD) system’s initial assign tool did not identify the closest available resource.
cardiac arrest. interventions Limited organisational reviews of whether current techniques are still best practice. Investigate ways of improving clinical leadership at-scene. Develop a policy for the regular review of how clinical interventions are performed. Develop guidelines on how to perform patient care clinical interventions. Investigate adding intraosseous access to the paramedic scope of practice. Developed training plan that: incorporates leadership and high risk / low occurrence interventions for intensive care paramedics includes simulation sessions to support clinicians in application of these skills. Reviewed operational structure that will better support clinical leadership / performance of teams. Transport Provider Summary of event Root causes Recommendations Actions taken St John 0994SJA2015 No members were available to retrieve a specialist (bariatric) ambulance, which resulted in a prolonged scene time and delayed transport for a patient with urgent needs. Reliance on using patient transfer service (PTS) staff to retrieve the specialist ambulance. Introduce requirement that specialist bariatric ambulance be crewed 21 hours a day. Introduce powerlift stretchers that have a higher weight capacity. Develop policy and standard operating procedure for bariatric patient transfers. The bariatric ambulance is expected in 2017. The powerlift stretcher is operational and crewed 24 hours a day, 7 days a week. Training has been provided to PTS staff in the use of manual handling devices. Policy has been written. Technology Provider Summary of event Root causes Recommendations Actions St John 1828SJA2015 Software failure delayed an incident entering the dispatch No further investigation was able to be conducted. Nil. Software was upgraded, which addresses this type of failure. Communications centres Provider Summary of event Root causes Recommendations Actions taken St John 0992SJA2015 Possible delayed response of crew to helipad so helicopter could respond to motor vehicle crash. Unable to conclusively determine the root cause due to loss of activity log data during upgrade of computer aided dispatch (CAD) system. Not applicable. Not applicable. St John 1020SJA2015 The closest available resource was not responded to a red (potentially life threatening or time critical) incident. The dispatcher did not use the review or revise the incidents, as per the ‘respond, review and revise’ methodology. The computer aided dispatch (CAD) system’s initial assign tool did not identify the closest available resource. Dispatcher to review of the respond, review and revise methodology. Review enacted.