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You receive a complaint from a patient regarding a missed injury. The patient was discharged from the ED with a diagnosis of foot sprain. On subsequent assessment by her GP, she was found to have a Lisfranc injury requiring surgery at another hospital.

Systems factors such as ED workload, overcrowding or imaging delays should also be reviewed as part of a quality improvement approach.

1. State seven pieces of information you will seek from your investigation and provide justification for each. 7 marks

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2. Apart from your investigation, state five features of your management of this situation. 5 marks

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