4.1 Inter- and multidisciplinary collaboration in risk assessment procedures

Day 2

George tells the nurse:

• His buttocks (gluteal region) were painful overnight
• Repositioning was difficult
• He previously mentioned tailbone (coccyx) pain (ED, stretcher, staff)
• Staff did not react

The nurse inspects the sacral area.

Pause and reflect:

1. How could this have been avoided?
2. At which moments should risk assessment have occurred?
3. Which disciplines should have been involved?
4. Where did the system fail?