Finding into death of Josip Dobrovoljski

Contributing factors

• Inadequate documentation of protamine reaction on 26 August 2014 anaesthetic chart
• Protamine reaction not recorded in ICU admission note despite verbal handover
• Failure to communicate previous protamine reaction during handover from ICU to EP laboratory
• Surgical Safety Checklist not completed for 3 September 2014 procedure
• Team Time Out not conducted prior to ablation procedure
• Red alert bracelet covered by surgical drapes and not reviewed
• Anaesthetist did not definitively check alert documentation prior to protamine administration
• Previous anaesthetic chart did not document the protamine reaction
• Patient in perilous cardiac condition with multiple recent cardiac arrests

Coroner's recommendations

1. Royal Melbourne Hospital to develop a general guideline for the use of protamine, outlining indications, high-risk patients, potential complications and management options for high risk situations
2. Royal Melbourne Hospital to educate anaesthetists regarding the need to document any significant intraoperative event and medications administered
3. Royal Melbourne Hospital to amend Surgical Safety Checklist document to include adverse drug reactions as well as known allergies
4. Improve handover processes for collecting patients from ICU, including notification of allergies/adverse drug reactions, structured verbal clinical handover format, and designated handover location
5. Ensure Surgical Safety Checklist is completed by transferring unit for all patients and included as part of handover process
6. Clinicians directly involved in patient care must participate in handover
7. Patient must not be accepted for transfer unless all relevant documentation completed and formally handed over using ISBAR minimum data set
8. EP laboratory nursing staff must check and sign off Surgical Safety Checklist on acceptance of patient
9. Provide further education to ICU and EP laboratory medical and nursing staff on importance of Surgical Safety Checklist completion and Time Out conduct
10. Improve documentation of protamine reactions on anaesthetic chart, specifying type, severity and treatment required
11. Note allergy/sensitivity on front of anaesthetic chart alert section in addition to computerised patient master index and case note alerts
12. Develop policy reviewing indications for protamine use in non-cardiac theatre situations, considering current clinical state and presence/type/severity of previous reactions
13. Education on protamine administration—indications and methods