408 The Swiss Cheese Effect: Following Lower Limb Emergency Admissions Through Hospital

Abstract Introduction The Swiss cheese model analyses failure in a system: when holes align this creates ‘a trajectory of accident opportunity’. In healthcare could translate to morbidity and/or mortality patients. We investigated potential points treating lower limb injury patients through their hospital journey. Three were investigated: (1) prescription venous thrombo-embolism (VTE) prophylaxis, (2) operation note information and legibility (3) time delay post-operative blood tests. Method A total 105 emergency surgical identified retrospectively from two centres across the North West Region between 31/07/20 21/11/20. Data was collected on thrombo-prophylaxis, recorded, notes as per RCSEng full count compared recommendation. Results found that 10-55% prescribed anti-embolism stockings versus 100% given chemical anti-coagulation day 1 admission. Of 23 data points, mean number missing operative 4.90 (range: 2-10). 82.5% handwritten deemed legible. Post-operative counts ordered 83.3% patients, with first order ranging 1-5 days post operatively. Conclusions cumulative effect having these errors at all three greatly increases chance morbidity/mortality Our experience demonstrates meet trust Royal College Surgeon’s guidelines. aim re-audit nationally our planned intervention.