Northland Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 11 N/C Extreme weather associated with entry caused outage of patient management systems. Reliance on electronic systems. Knowledge deficits. Lack of contingency plans. Re-positioning of computer switchboard. Attention to maintenance. Develop contingency plans. Completed. Discussion by executive team. Business continuity plans under development. Serious 4A N/C Patient failed to progress in labour in regional hospital. Subsequent transfer, emergency caesarean, baby died. Relevant previous obstetric history might have prompted earlier transfer not obtained. Equipment shortage and resuscitation processes to be addressed. Regional midwives to be reminded of best practice re obtaining obstetric history. Foetal monitoring machine to be purchased for theatre. Completed at education session by Maternity Manager. Now four machines throughout the service. Sentinel 4A N/C Patient presented to emergency department x 3 over a six-year period. taken on each presentation identified pulmonary tuberculosis, not actioned until third presentation. X-ray results filed without action. New alert process on radiology reporting system. System for ensuring clinicians alerted to radiological abnormalities in process. Sentinel 4A 2 Mammogram identified potential carcinoma, referral never actioned. Diagnosis delayed until further presentation. No process for handing on patients when clinician leaves. Database of patients requiring annual mammograms. Radiology Department to proceed directly to biopsy if clinically indicated. Process of handover. System in place December 2008. Commence by January 2010. To be completed by November 2009. trial Trial
Serious 4B 2 Child received overdose of fluids. Misread guideline, using adult instead of paediatric section to calculate fluid. Limited review of treatment on transfer from emergency department to paediatric ward. Highlight paediatric section of guideline. Improve protocol access. implement smart pump technology. Develop and precalculated weight-based infusion guidelines. Develop transfer protocols for paediatric patients. Revise paediatric fluid guidelines. All implemented or underway. Sentinel 4D 1 Cardiac arrest during laparoscopic surgery. No clear risk factors. Likely rare complication of gas entering circulation. All treatment appropriate. Full complement of theatre staff even during low risk procedures. None required. Sentinel 3 1 Swab retained post surgery. Delayed recognition even though visible on x-rays. under review. Pending. Pending. Waitemata Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up trial
Serious 4b 3 Delayed treatment for high INR. Admitted for treatment post haemodialysis as INR 10.9. Delayed assessment in emergency department. Developed minor complications. Delayed administration of plasma and delayed Prothrombinex administration. Treatment to be given in haemodialysis unit. Increased supervision of treatment plans and prescriptions in emergency department. Staff advised to call nurse specialists if too busy. Serious 5 3 Medication incident. Patient prescribed 900 mgs of Amiodarone for 3D then 300 mg BD. 3D was interpreted as three days. Patient received 6 x 900 mgs over 48 hours. Very nauseated post angiogram. Found that non-standard abbreviation resulting in overdose of Amiodarone. Accepted abbreviations reinforced. Appropriate dosage reviewed with staff and increased vigilance reinforced. No long-term effects for patient. Serious 6 3 Fall unwitnessed resulting in fractured neck of femur and surgery. on floor in bathroom with walker nearby. Assessed as having fractured neck of femur and transferred for surgery. Rehabilitation prolonged. Resulted in relocation. Procedures for monitoring dependent patients when self mobilising reinforced. Review of bathroom layout. Serious 4a 3 Inadequate documentation of patient admitted for elective procedure. Patient admitted for elective procedure. Patient deteriorated with fatal post-op complications. At time of deterioration and medical registrar and ICU review, little information was found on the admission planner, or any subsequent evaluation (other than for knee surgery) despite being in hospital for five days. Elective assessment procedures reviewed to ensure complete documentation. Reinforcement of requirement for daily review and documentation in clinical record. Audited.
Serious 4c 3 Patient deterioration and delayed assessment. Early warning scoring inconsistent resulting in delayed assessment. Emergency call not made when the indicated it should have, despite doctor in attendance. Patient required transferred to ICU after initial stabilisation and had prolonged recovery. Staff knowledge and assessment skills using the early warning score reviewed. Reinforcement of emergency reviewed with staff. Staff training increased in the service and assessment skills reviewed. Serious 4d 3 Medication administration error. Morphine elixir via an IV line instead of a gastric tube. Medication checking process to the bed side inadequate. Dedicated syringe for gastric tubes not used in administration process. Best practice not followed. Increased supervision required. Equipment changed and staff trained to identify correct administration practice. Case review undertaken and used in teaching. Equipment change actioned. Sentinel 4d 2 Unexpected death following elective surgery. Underwent an elective inguinal hernia repair. Discharged home the next day. At home collapsed and died. Autopsy identified complication surgery. Pre discharge assessment requirements reviewed with staff. Service continuing to review this incident. Serious 11 2 Prolonged infection outbreak. Prolonged ESBL outbreak with colonisation of a number of patients. ESBL has contributed to infections which may have contributed to deaths of a few patients. Extensive outbreak management plan has been in place. Reviewed by CDC. Intensive and staff education programme in place. Services continuing to review this situation to ensure systems issues are addressed. Sentinel 4d 1 Unexpected death from complications of anticoagulation therapy. Admitted for treatment of myocardial infarction with Clexane and Aspirin. Deteriorated and transferred to ICU. CT scan showed bleeding from inferior epigastric artery associated with large rectus sheath haematoma. Transferred to the vascular service. Deceased. Administration practice of Clexane reviewed as appropriate. Case review used in staff teaching to increase awareness of recommended sites for administration in patient teaching. Continuous education process.
Serious 4a 2 Incorrect pathological diagnosis of type of tumour leading to inappropriate more toxic treatment at the time. Tumour histology incorrectly reported five ago. Patient suffered significant complications of treatment. No change to current systems required. Not applicable. Serious 6 2 Inpatient fall causing fractured wrist. Patient left in care of visiting family while staff were on break. Update / expand falls prevention programme. In progress. Serious 4b 2 Non-fatal cardiac arrest due to bleeding during caesarean section in high-risk patient. Inadequate planning of surgery and anaesthesia. Multi-disciplinary planning group for high-risk cases. Implemented. Technical difficulties during procedure. Specific credentialing for surgery. Proposal under review. Review use of arterial balloons. Process revised. Serious 4b 2 Delay in receiving follow-up after cancer surgery. Late identification and treatment of tumour recurrence. Post-op clinic appointment not sent due to communication failure. Patient co-ordinator position required. Nurse specialist appointed. Sentinel 4a 1 Failure to act on significant drop in patient’s haemoglobin. Patient died next day. Rest home requested blood test using form with incorrect details. Test request form to have correct contact details. Letter sent to rest home. Results sent to hospital staff who were on leave. Requestor responsible for followup of results. Laboratory did not contact rest home. Laboratory to review criteria for identification and communication of critical results. Issue raised with community laboratory. Sentinel 2 1 Inpatient suicide in mental health unit. Currently under review. Currently under review. Not applicable. Serious 4d 2 Severe pressure ulceration requiring surgery. High risk case in ICU. Cardiovascular instability limited frequency of patient turns. Modify education regarding early risk assessment. Implemented. Early signs of injury not recognised. Revise approach to turns for unstable patients. Serious 8 2 Client requiring escorted leave absconded from temporarily locked ward and attempted suicide. Client left as staff member entered. Identity of patient and leave status was not known. Placement in open ward was appropriate. Review monitoring and security systems for clients requiring leave supervision in open wards. In progress.
Serious 4b 2 Bleeding from lung unable to be suctioned due to inadequate equipment. Room not appropriately prepared for complexity of patient. Delay in resuscitation team arriving due to unfamiliar location. range of equipment with improved labelling. Implemented. Increase nursing cover in evenings. Implemented. Modify resus team teaching. Implemented. Serious 5 2 Incorrect dose (20x) of concentrated sodium to IV fluids. Patient developed critically high sodium level. 4 mmol/ml misunderstood as 4 mmol per 20 ml ampoule. Labelling change. In progress with manufacturer. High concentration not emphasised on label. Revise IV fluid protocol. In progress. unfamiliar with concentrated saline. Staff education. Serious 6 2 Fall from radiology table during procedure causing lacerated scalp. In stable position stable for 45 minutes, but then turned and fell, assuming procedure had ended. Larger may have prevented fall. Death next day unrelated to this injury. Higher risk cases to use largest available table. More instructions to patients. Implemented. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand falls prevention programme. In progress. Serious 11 2 Major failure of clinical computer systems for four hours. Significant clinical risk. Replacement of uninterruptable power supply damaged by power “spike” caused sequential failure of multiple systems. Revised documentation to support maintenance operations. Completed. Inadequate knowledge of supply requirements. Higher level authorisation for equipment changes. Implemented. Key servers had single power supplies. Upgrade of all servers to fully separated dual power supply Mostly completed, some ongoing work. Serious 4b 2 Delay in recognising and acting on severity of deterioration of patient with pneumonia. probably not preventable, but intervention should have occurred some hours earlier. Improved communication between medical All staff involved aware of issues. Delay in senior medical review. Review of medical high dependency services. Review in progress. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand prevention programme. In progress. Trial trial
Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 1 1 Patient on heart monitor wrongly identified leading to delay in reviewing patient after alert by coronary care unit team. Emergency team called, but resuscitation unsuccessful and patient died. Incorrect and absent patient name labels above beds. Failure to check wrist band. Lack of bedside handover process. Vital signs not checked when coronary care unit requested patient review. extent of incorrect use of patient name labels in medical wards. Introduce bedside handover as part of Handover Project. Draft guidelines to ensure ward staff have clear understanding of expectations when asked by coronary care unit to review a patient. Audit completed. No ward achieved 100%. of patient labels on beds rather than wall above bed being considered. The handover communication tool is currently being trialed on three wards for shift to shift, bedside handover and documentation. This includes checking of patient identification. Draft procedure written and consultation in progress. Serious 3 2 Retained clip following surgery resulting in second procedure for removal. Changeover of nursing staff during procedure. Count not completed before skin closure. Introduction of Safer Surgery Checklist. Review count policy and procedures. Review and update theatre documentation sheets. Surgery Checklist project under way and reviewed with nursing staff and surgical governance group. Policy and procedures review completed. Theatre documentation sheets reviewed and update under way. Sentinel 4A 1 Late presentation of patient to maternity services (phoned when in labour) with unrecognised breech. Inadequate phone advice. Baby stillborn. No standardised phone advice process in Assessment and Labour Birthing Unit. No documented process for self referral antenatal bookings. Lack of agreed clinical prioritisation process for antenatal booking referral. Develop agreed process for managing unbooked women, with transparent clinical prioritisation criteria and agreed timeframes. Standardise the booking and grading process across the Women’s Health Service. In progress.
Sentinel 4A 1 Elderly man admitted to community hospital by general practitioner. Lack of recognition of physiological deterioration delayed admission to main hospital where patient died shortly after. Failure to recognise acuity of patient’s condition by medical and nursing Vital signs not consistently carried out and no fluid balance chart kept. Patient admitted to community to have minimum three sets of vital signs recorded in first 24 hours. Physiologically unstable patient protocol (adapted for community setting) to be followed for any patient assessed as unstable. Education for nursing staff to review accurate and timely recording and monitoring of vital signs and fluid balance. Physiologically unstable patient protocol currently reviewed for implementation in community hospitals. All registered staff in both community hospitals completed training in vital sign recording and monitoring to recognise clinical deterioration. Serious 4A 2 Eye disease in premature baby not picked up at screening resulting in significantly impaired vision in one eye. Service reliant on single ophthalmologist causing problems when covering leave. Limited peer review / audit. Recall programme for all babies previously screened by doctor undertaken with assistance from Neonatal Unit New paediatric ophthalmologist being recruited and job description to specify clinical competencies in greater detail. Develop system for clinical audit of screening process. All babies were recalled and re-examined. Recruitment underway and job description updated. National auditing completed. Serious 4C 2 Serious tissue injury to baby’s hand from intravenous (IV) line requiring surgery. Good recovery. Fluid balance chart doesn’t facilitate documentation of IV checks. Scoring tool not used to assess IV site. Splinting used in paediatric patients to secure the IV site hides development of complications. Redesign current paediatric fluid balance chart. Incorporate scoring tools into new fluid balance chart. Develop standards for IV splinting and securing for paediatric patients. New fluid balance chart implemented 01/07/2009. Scoring included in new fluid balance chart. Standards for IV securing and splinting in children developed and implemented.
Sentinel 4F 1 Urgent readmission within two hours of discharge. Patient subsequently died. Family concerns were not acted on upon discharge. Lack of clarity for family around care / treatment received. All senior nurses reminded to include family members in discussions on discharge planning, to clarify questions from family in writing and to organise further meeting if requested by family. Review communication with all surgical teams. having family present at ward rounds. Discussed at senior nurse forum – completed. Discussed at surgical governance forum. Case to be presented at a governance meeting with recommendations for of families to be present at ward rounds. Sentinel 4G 1 Cross infection in single unit between seven patients. Subsequent infection and sepsis in one patient resulting in death. Process not in place to ensure all multiuse equipment routinely cleaned between patients. Hand hygiene education by Infection Control nurse had not been effective in preventing further cross infection. Ensure personal protective equipment is implemented for multi-resistant patients. Review and modify cleaning process for all equipment that is multiuse to ensure it is appropriately cleaned. Raise ‘hand hygiene’ awareness. Unit manager enforcing use of personal protective equipment appropriate. Cleaning process review in progress. Hand hygiene coordinator appointed and hand hygiene project currently implemented organisation wide. Serious 5 2 Incorrect administration of medication requiring antidote and transfer to Coronary Care Unit. Full recovery. Correct protocol not accessed. Correct process not followed to administer controlled drug. Discrepancy between nursing and pharmacy protocols for administration of controlled drugs. Inaccurate documentation of dose given in notes. Review process for accessing protocols and administering controlled drugs with nursing staff. Nursing and pharmacy to review and amend polices so they align. Documentation and communication re administration of medication to be incorporated into orientation training for new graduates. Education about accessing protocols and administering controlled drugs completed January 2009. Pharmacy currently reviewing and modifying policies. In progress plus additional ‘socialisation / orientation’ one-day programme run for new nursing staff with focus on expectations and communication.
Serious 6 2 Patient fall resulting in fractured pelvis. Patient’s condition changed – became confused and unstable on feet. No falls risk assessment completed. As above. As above. Serious 6 2 Patient fall resulting in fractured hip requiring surgery. Review of new bathroom layout revealed issues, including placement of grab rails, lighting and floor surface. Investigation of this fall also highlighted that flooring in new building was exceptionally slippery. Cleaning services inappropriately applied six layers of sealant to the floors in new building making them slippery. Inadequate communication with cleaning services re management of new floor surfaces. As plus: Comprehensive risk assessment undertaken by Occupational Health and Safety and sealant to be removed. Review process for communicating with Cleaning Services re appropriate treatment for new flooring. Implement control measures to reduce and manage spillages. Investigate ‘dry’ cleaning methods to avoid wet floors. Review process of floor specification and selection in new buildings. As above plus: Comprehensive risk assessment completed and sealant removed. Working group set up to consider development of a specification for new bathrooms and flooring based upon slip-resistance criteria and to establish process for communicating with cleaning staff re appropriate treatment to clean floors. Serious 11 2 Patient injured when anaesthetist inject anaesthetic into patient’s eye, was bumped by someone in the adjacent cubicle. Procedure delayed, but later completed with no lasting harm to the patient. Soft curtains between cubicles. High traffic area. Ward beds leave little room for staff in narrow cubicles. Identify safe area for procedure to be performed with hard between cubicles. barrier (bar) placed between beds. Monitoring continues. Serious 11 2 Theatre table extension gave way resulting in neck injury to patient. Patient readmitted for MRI and investigation of ongoing neck problems. lack of knowledge regarding fitting the extension and no identifying marks to match the catch and pipe. Extension not checked before use and no safety mechanism to ensure the extension will not detach during use. Bed to be assessed by engineering and appropriate modifications made to ensure safety of attachment. Future beds to have suitable xray attachments. Bed assessed and modifications completed by engineering. Discussed in theatre meeting. Safer surgery checklist project under way.
Sentinel MH 1 1 Suicide of a person subject to the Mental Health Act 1992. Limited family understanding of risk and their role in managing risk. Information sharing regarding NGO involvement with client was inadequate. Close liaison with families on what constitutes risk and how psychosis impacts on judgment, function and communication. Providers to have robust process in place and a standard process for information sharing. Actions completed or way. Coroners report sent. Sentinel MH 3 1 Suspected suicide of an outpatient not subject to the Mental Health Act 1992 who is being actively managed by mental health services. Unclear expectations re second opinion. Handover from crisis team to general team members was unclear level of follow up required. Liaison with GP was delayed as there was no clarification about diagnosis. Clear direction for second opinion to be drafted and circulated to ensure clarity of responsibilities including crisis team role to review and update risk assessment prior to hand over to general team. A letter is to be sent to the general practitioner with working diagnosis. Actions complete. Coroners report completed. Sentinel MH 3 1 Suspected suicide of an outpatient not subject to the Mental Health Act 1992 who is being actively managed by mental health services. Recent changes in risk unclear in the risk assessment. Information sharing between provider staff re changes in risk could improve. Information known to the family not made known to the clinical team due to lack of engagement with family members who were overseas during crisis period. A new risk assessment and management plan to clearly reflect changes to risk. Process to be in place to ensure that all staff formally notify crisis staff of any deviation from agreed plan. Crisis staff to actively make contact with known primary caregivers and family members if a person is experiencing a significant period of crisis even if they are overseas. Actions complete or under way. Waikato
Serious 6 1 Patient fall resulting in an injury that required surgery to repair. Patient’s clinical condition contributed to the fall. To undertake a DHB-wide project to identify best practice strategies to reduce patient harm from falls. Implementation of falls project recommendations under way. Serious 4(b) 1 Patient had radiology investigation that was not followed up. Failure to recognise and or action a significant incidental finding in this case an aortic abdominal aneurysm on an inpatient between May and June 2008. The conclusion/impression section of radiology reports will firstly include the findings/ abnormalities in answer to the clinical question being asked and thereafter any other significant incidental findings should be listed. In progress. Serious 11 2 Patient injured by bed rail. Patients underlying condition increased susceptibility of injury. Ward to complete feasibility of assignment of padded bed rails to specific inpatient population. Include learnings from this event in the education schedule for the ward. Completed. Serious 6 2 Patient fall with resulting injury sustained. Wet floor area caused patient to slip. Non-slip lino to be replaced by end 2008 as part of property and infrastructure upgrade programme. Completed. Serious 6 2 Patient fall with resulting injury sustained. Patient fell whilst attempting to turn television off. Patient left sitting in lazy boy for longer period than normal due to nurse workload. Discussion to occur with staff on risks in use of televisions, and management of workloads. Controls to be documented for dealing with low staffing risks. In progress. Serious 6 2 Patient fall with resulting injury sustained Incomplete risk assessment carried out and patients clinical condition contributed to the fall. Ensure admissions are vetted for appropriateness and that a clear admission process is completed on admission. Sensor mats to be sourced. In progress. Serious 11 2 Patient hit leg on side of wheelchair. Required surgery to repair and ongoing plastic surgery treatment. Review in progress.
Serious 4b 2 Patient’s condition deteriorating. Slow response from medical team to review. Review in progress. Serious 11 2 Physical assault by patient whilst on leave from inpatient facility. Ensure appropriate accommodation on discharge. Ensure discharge planning process considers appropriate discharge accommodation. In progress. Serious 4b 2 Patient had x-ray of hand and there was a delay in taking action of the result. Had fractured hand. Review in progress. Serious 6 2 Patient fall with resulting injury sustained. Review in progress. Serious 11 2 Patient had neurosurgical drain removed in error. Patient had to return to theatre for re-insertion. Drain very similar in colour to other drains in use, making it easy to remove incorrect drain. Change drain type to coloured to reduce risk of similar event recurring. In progress. Serious 4a 2 Delayed diagnosis and assessment of patient due to self discharge and incomplete assessment by staff. No follow-up provided – was to be discussed at mortality and morbidity meeting. Serious 4g 2 Communication issues between departments. Review in progress. Serious 11 2 Wrong body uplifted from mortuary. The funeral director did not check the identification of the body being uplifted. The procedures describing the process for persons uplifting bodies are not readily accessible at the point of transfer in the mortuary and have not been circulated to relevant parties such as funeral directors. This contributed to the confusion regarding who was responsible for identifying the body. Review mortuary procedures relating to persons depositing or removing bodies plus DHB Care of deceased policy and procedure. Draft mortuary procedures to be circulated to funeral directors for comment. Controlled copies of final procedures to be distributed to funeral directors. In progress.
Serious 6 1 Patient fall with resulting injury sustained. This was not diagnosed until patient was discharged from hospital. Patient readmitted for surgery. Patients confused and tried to mobilise without calling for staff assistance. No falls risk assessment. No falls mitigation strategies documented or implemented. Neither the falls risk assessment nor the mitigation strategies were reassessed and revised after fall. Staff members to sign that they have read and understood the Inpatient Falls Assessment and Management Protocol. Falls Protocol to be complied with as evidenced by compliance audit results. Audit to be conducted by Q&R Standards and Audit Facilitator. Hourly rounds to be implemented as part of nursing model. risk management education to be provided to all staff. Implementation of falls project recommendations under way. Serious 6 1 Patient fell and sustained fractured hip and required surgical repair. Patients confused and tried to mobilise without calling for staff assistance. protocol to be complied with as evidenced by compliance audit results. Implementation of falls project recommendations under way. Serious 6 1 Seven patient falls events. Falls project completed November 2009. Increase compliance with existing Waikato DHB falls risk minimisation strategies through audit, education and nursing rounds. Ongoing monitoring of falls and compliance with organisational requirements. Implementation of project recommendations under way. Serious 11 1 Outpatient suicide within seven days of last contact with service. RCA review in progress. Serious 4c 1 Patient was not monitored as per requirements. RCA review in progress.
Serious 4a 1 Surgery delay for patient with severe finger injury. Multiple missed opportunities, to recognise the severity of the patient’s infected finger combined with theatre delays contributed to the patient’s finger being severely infected preoperatively and the patient having decreased functional use of his left index finger post operatively. Referral system be reviewed and improved to ensure more timely and formalised booking process. Medical handover process to be developed. In progress. Serious 4a 1 CTG not recognised as abnormal – baby died two days RCA review in progress. Serious 11 1 Client attempted suicide within the inpatient facility and died from her injuries. RCA review in progress. Serious 3 1 Retained needle following surgical procedure. No root causes Other learnings identified. Open disclosure education package to be developed and provided to clinical staff. In progress. Serious 11 1 Outpatient suicide one day after contact with service. RCA review in progress. Serious 4a 1 Delay in diagnosis due to delay in accessing imaging result. RCA review in progress. Serious 1 1 Wrong patient had investigative procedure. RCA review in progress. Serious 11 1 Outpatient suicide within seven days of discharge from inpatient area. RCA review in progress. Serious 4a 1 Patient died from sepsis. Had presented multiple to hospital and was reviewed by numerous teams. Multiple missed opportunities to recognise the patient’s deterioration and missed opportunities for more senior and experienced staff to intervene and manage the patient’s deterioration in a timely and effective way contributed to the patient’s death from overwhelming sepsis. The development and implementation of a new rapid response system. Development of an recognition and management of sepsis’ pathway for the emergency department. In progress.
8 and 11 2 Despite efforts to stop patient they ran from hospital and jumped off a bridge. Sustained multiple injuries. There was a lack of communication between the mental health and ward staff as to the level of observation required. Ensure all information documented by the mental health team is consistent and available to general hospitals in instances where current mental health intervention is being given. Review and formalise the processes, for assigning and prioritising levels of observation. Review practices related to patients who present following a self harm attempt are medically cleared and remain in hospital as they are too sedated for a mental status examination to be completed. Subject to HDC Investigation. Lakes Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Serious 6 2 High falls risk patient was not supervised by appropriately qualified staff in the shower resulting in a fall and dislocation of hip requiring surgical intervention. Historical contract with staff to assist male patients showering had been terminated in all other wards apart from this ward. Showering assistance contract with staff terminated. No further incidents. Sentinel 4B 1 Identified as a placental abruption however inadequate monitoring of complicated labouring mother and delay in transfer of care resulting in compromised baby. Baby electronic monitoring (CTG) not adequate. Transfer of care not implemented in a timely manner. Obstetrician conducted review of case to identify time of compromising. Independent review of midwifery care. Baby electronic monitoring (CTG) training for midwives. Review policies/processes to identify transfer criteria. CTG scheduled within next six months and thereafter. CTG and documentation education under development. Transfer guideline implemented.
Serious 6 2 Cognitively compromised high falls risk patient inadequately monitored resulting in fall and fractured hip. High falls risk patient did not have a care plan completed therefore patient need for increased monitoring not identified. education on falls policy and process and on identification of patients in need of close monitoring. Audit of compliance to be conducted on six-monthly basis. Regular review of trended falls data by newly established Falls Committee to support improvement opportunities. Tairawhiti Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up 4B 1 Unexpected deterioration and death following acute hernia repair operation. Cause of deterioration difficult to determine. Multiple co morbidities added to the complexity of patients condition. Initial response reassuring however further deterioration and to interventions. Both surgeon and anaesthetist to be called for deteriorating patients. A structured communication tool to be used to improve effective communication of patients condition. Patients admitted unexpectedly to ICU following surgery need a thorough handover process should happen including clear treatment plan (with target parameters, etc) written in the notes as well as all treatments and fluids properly charted. In most cases, a direct hand over by the doctor(s) to the ICU nurse should occur. Develop a range of standardised blood tests that should be taken shortly after admission in order to have some baseline indication and in some case to detect early the need for some therapeutic adjustments. Patients with co morbidities to be scheduled in the day. Coroner’s report pending. Recommendations implemented.
1 side prosthesis inserted during elective surgery resulting is further surgery. Timeout procedure did not include prosthesis couple with staff unfamiliar with the prosthetics the wrong side was used. Replacement was not necessary and patient has gained full range of function. Timeout guidelines improved to include equipment check. Improve labelling and storage of prosthetics. Improve cross-skilling of staff to reduce reliance on individuals. RCA completed. Recommendations implemented. Variable practice regarding the use of foetal monitoring during labour resulting in in recognition of foetal distress. Develop and implement risk assessment tool for intrapartum to be carried out on admission to the unit. Include risk information in handover sheets and identify on the whiteboard. Review workforce issues staff in primary and secondary care to improve workplace culture. A structured communication tool be used to improve effective communication of patients condition between professionals. Develop formal procedure for obtaining second opinion to review CTG trace. Implement education package for the appropriate documentation and assessment of CTG tracings. Establish minimum requirements training as a with annual recertification. Develop an additional clause for the Section 88 schedule 3 which reminds LMCs of their obligations under the HPCA Act to work within scope of practice and to take regular breaks to minimise risk of fatigue. Ensure LMCs have arrangements with a backup LMC for provision of periods of planned and unplanned leaver that enable 24/7 cover. Standardise CTG monitors to reduce margin of in setting alarm parameters. Set default to the normal limits of a reassuring trace. Educate staff on the use of alarms. Prevent mute of FHR and alarms. Referred to coroner. RCA completed – recommendations being implemented.
Not all staff were carrying a duress alarm. Delay in contacting the responsible clinician. Emergency response delay. All to be trained in calming and restraint. Completed and ongoing. All staff are to carry a duress alarm in the intensive psychiatric care unit at all times. Compliance be audited. Completed and ongoing. Processes re contacting responsible clinician to be communicated at staff meetings. Completed. New protocol and process to be introduced for emergency response and site map pre-set into ambulance location. Completed. Whanganui Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up Serious 4A 2 Eighteen-month delay in responding to an abnormal chest X-ray, resulting in the need for extensive treatment. Inconsistent application of “red flag” process in radiology. No process, at the time, for communicating the results to the patient’s GP. Delays in both reporting the Xray and reviewing the X-ray. “Red flag” alert process reiterated to all radiologists and audited by the team leader. All radiology reports ordered by District Health Board consultants are now copied to the patient’s GP. Joint venture with Pacific Radiology has provided additional resource and minimised delays. Further audit of “red flag” alert process in six months. Serious 11 2 Patient collapsed and died during second stage of labour. Postmortem indicated cause of death was an amniotic fluid embolus.
11 2 person was admitted to inpatient unit and sustained injury. Patient outcome: fracture of the humerus. Injury occurred during the restraint procedure where both the coordination and the technique used were contributing factors to the injury. It appeared that the restraint procedures used by the two organisations differed and the roles and responsibilities of the employees of the two organisations need clarifying. Calming and restraint should be undertaken by trained health only. When a young person requires admission immediate referral to tertiary provider should be actioned. Admission to an secondary health unit should be for the shortest time necessary. Improved communication between secondary and tertiary health providers for timely and efficient transfer of young people. Staff appropriately trained. 4B SAC1 Shoulder dystocia. Patient outcome: neonatal death. Baby transferred to tertiary hospital and subsequently died. Possible deficiencies in foetal monitoring. RCA commenced. RCA commenced 4A SAC 1 Patient discharged without full investigations. Patient outcome: unexpected death following accident. Patient presented via ambulance as a result of a car accident. Upon arrival patient was assessed and was discharged home. Patient died five days later. A subsequent post mortem found that patient died as a direct result of injuries that were received in the motor vehicle accident. SMO lead patient handover. Three definitive shift start times to assist with handover. Improvements and changes to handover embedded. Improved number of senior medical staff in post. 6G SAC2 Fall whilst an inpatient. Patient outcome: displacement of existing fractured tibia/fibula. Patient on bed rest and aware of the requirement for bed rest. Leaned to locker and fell out of bed. Patient assessed and found to have displaced the previous relocation of tibia/fibia. Taken back to theatre for another relocation. To ensure those patients on bed rest have equipment placed within a safe reaching distance, and have access to their call bell. Reminders to nursing staff and care assistants.
6C SAC2 Fall whilst an inpatient. Patient outcome: fractured left tibia. Patient admitted after stroke. Increased confusion and history of Alzheimer’s. On falls prevention programme as assessed as at risk of falls. Patient room was away from nursing station. Identified as requiring level 2 observation (15 minute) but not completed at every interval. Patient placed on toileting plan (every two hours) but also not completed at required times. Consistent documentation to be completed by all staff when patients on falls/observation programmes. Ongoing assessment and evaluation of risk factors around the patients falls risks. Assessment and evaluation of urinary elimination with toileting plan if applicable implemented. Use of Invisabeam monitoring in lieu of having an environment where patients can be continuously observed by staff. In progress. 6G 2 Fall whilst an inpatient. Patient outcome: fractured left neck of femur. Patient with dementia, confused and disorientated. Plan in place to discharge. Hip protectors in place as constant observation was discontinued as per discharge plan. Patient mobilising with frame and assistance from staff. Gradual discontinuation of specialling of dementia patients rather than an immediate stop to for ongoing assessment of needs of patients. In progress. Wairarapa Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Serious 6 N/C Inpatient fall sustaining a # ulna. Patient was documented as falls risk and precautions identified. On one-to-one observations in place. No recommendations which would have prevented this incident as process had been followed however it was reviewed as part of the Falls Management Group. Closed. Serious 6 N/C Inpatient fall sustaining a #NOF. Patient stated he was using elbow crutches incorrectly, did not realise until the crutch slipped. No recommendations which would have prevented this incident as process had been followed however it was reviewed as part of the Falls Management Group. Closed.
Hutt Valley Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 4B 1 Patient with disability underwent abdominal feeding tube insertion procedure. Bowel perforated during the surgical insertion procedure. This complication not diagnosed immediately, and patient subsequently died from infection. An internal and external review undertaken. A wide ranging set of recommendations were made as a result of the review process. NB: Patient died in May 2008 so this should have been reported in the previous serious/sentinel report to 30 June 2008. Most of the recommendations relate to improvements required in the assessment and planning of care for people with disabilities, especially when in the acute care setting. A comprehensive action plan based on the recommendations of the external reviewers is in place and under regular review. The summary report and actions were shared with the Health and Disability Commissioners, the Ministry of Health, the media and all District Health Boards. Progress against the action plan is monitored quarterly: eg, May 2009, August 2009, November 2009, and February 2010. Sentinel 4B 1 Patient with disability died following complications abdominal surgery. There were delays in the patient being assessed by a surgical registrar in the emergency department, inadequate nursing care and failure to take account of the patient’s disability needs. The health and Disability Commissioner found Hutt Valley DHB in breach of Right 4 of the Code of Health and Disability Services Consumers Rights, stating that the patient did not receive an appropriate standard of care. NB: The patient died in March 2008 so this should have been reported in the previous serious/sentinel report to 30/06/08. Improvements required in the way assessment and care planning meets the needs of disabled persons in the acute setting (linked to the above case). Improvements in the electronic record functions in the emergency department. Review of the surgical registrar role in relation to time taken to see patients in the emergency department. Review of training provided to nursing staff for male catheterisation. Ensure emergency department records accompany patient’s admitted to inpatient wards. Review of the informed consent policy regarding patients not competent to give informed consent. All recommendations are currently being worked on with progress reported quarterly as part of the case listed above. Work also continues on meeting the target for waiting times in the emergency department. A project to manage the flow of acute patients who require surgery has been completed, achieving improved coordination and decreased waiting times for such patients.
Serious 4D 2 Patient undergoing contrast tomography (CT) scan developed swelling and subsequent scarring when the contrast medium used for the scan infiltrated into arm tissue. The contrast was being delivered via a tube in the patient’s arm which became displaced at some stage during the procedure. An internal review highlighted that additional information was needed on the consent form signed by patients for CT scan, and that it was difficult for patients to alert staff if they needed assistance immediately. The Health and Disability Commissioner is currently reviewing our response to the complaint lodged by the patient. The consent form for CT scanning now includes an explanation of risks. A bell has been installed in the CT scanner to enable patients to call for assistance during a scan. Patient has received plastic surgery for the scarring on their arm, and is under ongoing review by hand and scar therapists. We await the outcome of the Health and Disability Commissioner review. Serious 4D 2 Patient had tube inserted to assist with feeding into the bloodstream. Four days insertion the patient experienced pain and shortness of breath. Chest X-ray showed tube had perforated into chest causing infection. Tube placement tip confirmed by x-ray as being just within correct placement. Chest x-ray taken four days later to check placement due to patient complaint of pain. Patient transferred to ICU as they developed respiratory complications. collections drained via a chest drain, and patient made a good recovery. IV policy states: a) that the tip position should always be verified by a radiographer prior to use in a clinical areas b) that nursing staff should undertake checking procedures to ensure placement is correct c) if in doubt, a chest X-ray should be performed prior to continuing or recommencing fluid infusion. No further action required. Serious 6 2 Inpatient fall resulting in broken wrist. Patient had been assessed for falls risk on admission, and had been graded as at moderate risk and appropriate precautions for that level of risk were implemented. Patient’s falls risk assessment upgraded from moderate to high. Patient placed in close observation cubicle, and medical and nursing care plan documented. Serious 6 2 Inpatient fall resulting in fractured hip, requiring surgery. Patient assessed on admission and not considered to be at risk of falling as normally independent. The patient had been undergoing preparation for surgery , and this may have contributed to the fall. No recommendations.
April 2009 4D 2 Patient underwent chest drain insertion to relieve the fluid on the chest and shortness of breath. As the chest drain was inserted to drain the fluid, it pierced the patient’s heart. The patient was transferred to another District Health Board for successful removal of drain. Patient made full recovery. Enlarged heart size made the fluid look larger than it was. X-ray was two weeks prior and no other imaging undertaken. Exact location of drain not obvious from documentation. Patient and next of kin fully communicated with during and following procedure. Clinical review completed. Recommendations: That a recent x-ray is undertaken prior to the procedure and is viewed prior to and during the procedure. That advice is sought from the respiratory physician if clinically indicated. That the informed consent process is clearly documented in the clinical record. Attendance at teaching and training sessions for medical be recorded. All recommendations communicated to medical staff as part of ongoing education following clinical review. 2008 4B 2 Patient admitted with inflammation on leg. Patient developed a pressure sore from being immobile and required surgery. Classified by ACC as a serious treatment injury. Clinical review complete. Areas of concern raised: Ability of junior nursing staff to assess skin and general condition of complex patients on admission, and in the event of their health status changing. Skin assessment tool did not reflect other complications. Contact has been made with family to acknowledge and apologise for the quality of care issues highlighted. Recommendations: Junior nurses to be upskilled in patient assessment process. Visual skin assessment to be included in patient notes. Action plan and timeframe for completion to be completed. Service to develop guidelines with support from Pacific and Maori Health Units, and Disability Advisor for use when family/caregivers wish to be involved with care. Action plan for service in place and all recommendations being progressed.
August 2008 5 1 Patient admitted to emergency department with a hip fracture. The patient was treated and discharged home, and prescribed a inflammatory medication for pain. The patient represented, with a bleeding stomach ulcer and subsequently died. Patient was treated for the initial bleeding stomach ulcer, but developed further bleeding and later died. The emergency department has implemented a policy ensuring the safe prescribing of non-steroidal inflammatory medications to elderly patients. Policy in and education of clinical staff in the emergency department on the policy has occurred through the clinical head of department. Capital & Coast Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 11 1 Possible anaphylactic reaction to antibiotic. Patient deceased. The review team found that clinical management was appropriate but that the system for medication alerts did not provide a clear, current and accessible history of medication sensitivities. Review recommended: improving the system for medication alerts feedback of learning from this event to staff. Action plan in progress. Serious 4C 2 Patient with peripheral central line developed clot in arm The review team found issues across the multidisciplinary team relating to peripheral central line management. Review recommended: staff education re post insertion care and management improved information reinstate steering group to provide oversight, audit, monitor and respond to issues ongoing. Action plan in progress.
Serious 4A and B 2 A patient had treatment of a more extensive nature than would usually have been offered had it been known that the patient had metastatic disease at the time that treatment options were being considered. The review team found that a report was not reviewed by the medical team until six months later. This was due to incomplete records and communication of information. Review recommended: notification to all SMOs regarding the event offering the patient an apology and explanation with the outcome of the review update of the risk register and mitigations to reflect the outcome of this event. Action plan in progress. Serious 4D NC Patient admitted for a fractured arm and vascular injury – went onto develop nerve injury and associated foot drop during admission. The review team found that the foot drop and nerve problems most likely resulted during care provided and subsequent to original injury. Review recommended: response to complaint and apology type of anaesthesia remain a clinical decision risks that arise when assumptions are made and included in clinical documentation be communicated to staff feedback regarding expected documentation standard. Action plan complete and closed. Followup audit of documentation is planned. Serious 4G NC a patient was anaesthetised it was identified that consent for the procedure had not been gained. The patient was woken and the procedure rescheduled. The review team found the anaesthetic consent was mistaken for procedural consent when pre-procedure checks were completed. Review recommended: review of service practice for gaining consent to support compliance with informed consent policy redesign of service pre procedure check lists provide findings to team revising informed consent policy and teams involved review orientation. Action plan complete and closed. Followup audit planned.
Sentinel 4C 1 A patient admitted with chest pain went onto develop a life threatening cardiac rhythm. The patient’s cardiac monitor did not alarm which delayed a medical response. Resuscitation unsuccessful. Review found that immediate medical response did not follow the advent of a life threatening arrhythmia because the cardiac monitor did not alarm. The root cause for the alarms not activating appeared to be because the audible alarms on the cardiac monitor were turned off. The patient’s family were not contacted when the patient was admitted. Review recommended: the planned purchase and installation of the new cardiac monitoring system be completed staff orientation be reviewed all patients admitted to the service be asked if they would like their family informed. Action plan almost complete including replacement of cardiac monitors – one recommendation still in progress. Serious 6 NC Outpatient fell in car park and sustained fracture. Review found that severe wind gusts blew the patient over and injury resulted. Review did not make specific recommendations. Serious 6 NC Inpatient fall with fracture Review found the patient had been identified as a high falls risk. Falls prevention strategies were in place. Some documentation incomplete. Review recommended: improved documentation of risk assessments compliance audit. Action plan complete and closed. Ongoing monitoring of falls in place. Serious 6 2 Inpatient fall with fracture. Patient deceased a few hours later. Under review – draft report in development. Serious 6 2 Inpatient fall with fracture. Review found that this fall occurred without warning; relevant falls risk management was in place including direct supervision when mobilising and that this was an unfortunate event rather than an event that arose as a result of a deficiency in systems or processes of care. Review did not make specific recommendations that would have prevented this fall from occurring. Action plan complete and closed. Ongoing monitoring of in place.
Serious 11 Patient died at home 24 hours after being discharged. Review found communication between service providers was fragmented and that the practice of planning discharge on Fridays created risk in this specific situation due to significant change in service provision process required for weekend cover. Review recommended: improved internal and external interagency communication amended discharge planning relevant. Action plan almost complete – one recommendation in progress. Serious 5 Medication error resulting in cardiac arrest. Patient resuscitated, required admission to ICU, returned to ward and later discharged. The review found of primary importance was the practice of storing a potentially dangerous medication next to a commonly used relatively innocuous medication. Omission of double checking, bedside checking and human factors contributed. Review also noted an issue with look alike medications – the plastic ampoules looked similar and the differences in visual presentation are not a significant barrier to misidentifying the medication being selected. Review recommended: urgent review of the storage of and access to the medication across all clinical areas review of medication cupboards in the service separation and clear identification of dangerous medications review of hospital wide intravenous (IV) certification processes and education to ensure risks of the medication are highlighted to all clinical staff. Action plan is in progress: quality improvement convened to implement actions from the review findings circulated to other DHBs, Pharmac and QIC Safe Use of Medicines Group newsletter to all clinical staff. Serious 5 Medication resulting in reaction and tinnitus later reported. Review found that this error occurred because a ‘medication added’ label was not attached to the syringe containing the antibiotic. There was also a delay between the preparation and administration. Review recommended: requirement for ‘medication label fastened securely to syringe. Use of second medication added label required when titrating (rate/dose adjustment) inform family when administering medications staff education. Action plan almost complete – one recommendation in progress. Serious 4a Missed diagnosis – permanent harm resulted. Review found that clinical examination findings were not compatible with the diagnosis, and that it was likely that a change had occurred in the clinical presentation subsequently. Review recommended: apology to the patient and provision of the report risk of error continue to be emphasised in training to staff. Action plan complete and closed.
Serious 11 2 Suspected suicide of community patient. Review in progress – report in draft. Serious 11 2 Self-harm by community patient. The review found that some documentation was lacking and that this made it difficulty to clearly understand the plan of care while the client was an inpatient, that the timing of discharge and level of care in the community was not what the family had expected. Recommendations related to use of client pathway documentation as per policy and completion of documentation of disciplinary reviews. Action plan in progress. Nelson / Marlborough Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Serious 1 2 Wrong site surgery. A back operation was done at the level requiring a second operation. Fusion L4/L5 instead of L5/S1. Contributing to this error was poor image quality. Patient recovered well after a second procedure. Orthopaedic surgeons should agree on a guideline of using the old intensifier. SMOs should be reminded that concerns about equipment quality and availability need to be formally documented to district managers. Guidelines agreed. SMOs reminded. Serious 4c 2 A patient had a respiratory arrest while waiting for a procedure in theatre. Patient was given morphine in ED and transferred to theatre where has was left alone in the anaesthetic room. When the nurse entered the room, she noticed the patient deeply cyanosed. He was resuscitated and recovered well. The policy on transferring patients should be completed. A policy should be developed to the care of patients while in operating theatre suites. This should include the principle that a patient is never to be left alone. Policy completed. Policy developed.
Sentinel 4a 1 A patient died in hospital due to a delay in diagnosis and treatment. A CT abdomen was delayed and a sub-phrenic abscess, due to ruptured gallbladder, was only discovered some days admission. There was a misunderstanding between the consultant and house surgeon as well as difficulties in communication between surgical consultants and between the surgical and medical teams and the family. A process for clear, effective, written handover between consultants, especially at weekends should be developed. Process agreed. West Coast Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up Serious 11 N/c Sterile cannulated drill guide found to be contaminated prior to use on patient. guide had not been processed correctly. Steps implemented to improve checking system. Serious 10 N/c Delay in care provided to patient; transfer of trauma patient requiring tertiary level ICU delayed due to combination of weather, secondary tertiary hospital unable to read electronic radiology report so unable to accept patient (although this was eventually sorted out), and retrieval team undertaking another transfer. Rare combination of events as both South Island tertiary hospitals unacceptable to accept transfers due to weather. Need to investigate compatibility issues regarding electronic reports between all tertiary hospitals that are potential recipients of patients from West Ongoing. Canterbury
Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 2, 8 1 Inpatient suicide of mental health inpatient. Patient left the ward unobserved. Improve security at external doors. Action completed. Sentinel 2, 8 1 Suicide of an inpatient whilst absent without leave. Risk status not updated following a change in the level of arousal of the patient. Observations undertaken but not documented. Mental state and risk assessment must be repeated as soon as a change in the level of arousal of patient is noted. Reinforcement of documentation requirements as stated in the “observation including specialling” policy. Recommendations underway Serious 4A 2 Patient seen in ED, reviewed by multiple services and discharged. Patient represented the following day, admitted and required surgical management. In hindsight the patient would have benefited from admission at first presentation. Difficulty in making initial diagnosis illustrated by cross referral across multiple services. No consistent rule regarding involvement of specialist when decision to not admit a patient under a particular service. Registrar may not decline an admission without prior consultation with their specialist on call. Actions completed. Sentinel 4 A, B, C 1 Patient with increasing confusion managed on ward with sedation and observation. Found in cardiac arrest. Admitted to ICU. Patient died. Lack of awareness of plan of care for patients with delirium. Use of early warning score tool and triggers for referral to ICU outreach team. Role of the intensive care outreach team. Education and care pathways required regarding acute delirium. Incorporate the EWS in calls to the Clinical Team Coordinator to act as a prompt to further identify the deteriorating patient. Continuing education on the role of the ICU outreach the team required. Actions underway Sentinel 4B 1 Suicide of a mental health outpatient in the emergency department. Lack of integration between psychiatric emergency services (PES) and emergency department (ED). Establishment of a multidisciplinary review group from PES and ED to improve integration between the two services. Introduce a triage system based on the MoH ED Mental Health Triage Guidelines. Establishment of a 24-hour psychiatric ED liaison position based in ED. Introduce structures to enable increased levels of observation in ED. Review policies and procedures on the transfer of identified patients to ED. All recommendations have been implemented.
Sentinel 4B 1 Cellphone failure resulted in in obtaining specialist support necessitating emergency procedure to be commenced by registrar inexperience in this procedure. Patient survived procedure but died at a later time. Procedures for obtaining alternative specialist support required. Failure of cellphone without alternative back options available. Procedures for obtaining alternative specialist support to be developed. Action completed. Serious 4D 2 Neonatal death of an extremely premature baby following insertion of an endotracheal tube (ETT). Dislodgement of ETT tube not recognised clinically or radiologically. The prematurity of the baby’s skin caused difficulties in adequately securing the ETT in place. The difficulty of detecting this complication radiologically in neonates resulted in the dislodgement not being noted. The baby’s admission occurred “after hours”. This resulted in a delay of regular Radiology review of the chest X-ray until the following morning. Movements of the baby’s head should be minimised to prevent the chance of ETT movement. That the X-rays in this case and any others of malpositioned ETT are maintained in a deidentified form to be utilised for teaching purposes. The introduction of a double check protocol for ETT placement. A review of current policy with regards to the frequency and method of checking an ETT placement where there is difficulty in securing the ETT. These recommendations are currently being implemented. Sentinel 4G 1 Recently discharged mental health outpatient found dead from suicide. No causal factors identified. No recommendations. Nil Sentinel 4G 1 Suicide of mental health outpatient. RCA under way. Report awaited. Sentinel 4F 1 Unexpected death of patient following discharge from ICU who had received reversal of narcotic. Possibility that the patient became re-narcotised on the ward. Potential benefit from longer period of observation in ICU. Patient to remain in ICU and monitored for four post-narcotic reversal. Actions completed.
Serious 1 1 Wrong site procedure. Femoral nerve block indicated for the patient due to significant pain issues not resolving by the use of oral analgesia, position changes and traction. House surgeon advised by medical team to administer femoral nerve block and the patient was referred to the pain team for ongoing management. House surgeon asked the patient which leg was painful to which the patient reported the left leg (current issue was fractured distal right femur) as a stent was recently inserted in the patients left leg for treatment of peripheral vascular disease. A nerve block was then administered to the incorrect leg. Fracture site must always be identified by an arrow and date by the medical team using a permanent marker. Administration of all medications must follow the hospital guidelines using the five rights. Completed. Serious 4B 2 Patient burned. Patient in labour cared for by a lead maternity care midwife developed complications and required a caesarean delivery. On the way to the anaesthetic room burns to the patients’ upper thighs and stomach were sighted by the midwife. The burns were identified as being caused by over heated and prolonged use of heat packs. The burns required dressing. Review the maternity protocol for use of heat packs and advise the midwife to adhere to these. Education session for all midwives on the correct use of heat packs in labour. Completed. Serious 4B 2 Patient burned. Patient was in the delivery suite and complained of leg cramps. The lead maternity midwife applied heat packs. Post delivery the patient complained of painful legs. On examination patient was found to have burns on both legs. The burns did not require dressing. Update for all midwives on the dangers of incorrect heat pack use and the importance of correct positioning of women in lithotomy. Completed
Serious 6 2 Patient fall, fractured arm. Patient was a known high falls risk and had the call bell within reach, and bedsides insitu at night, to reduce the likelihood of mobilising independently. Patient had rung the bell for assistance but got out of bed unaided and was witnessed slipping to the floor as nursing staff got to room. X-ray examination confirmed a fractured Colles that required surgical intervention. All patients that are assessed to be high falls risk should have a falls alarm in situ. Ensure all patients that are assessed to be high falls risk are toileted before settling at night. Completed. Falls prevention programme now in pilot phase. In progress. Serious 6 2 Patient fall, fractured left proximal femur. Patient was conservatively treated for a fractured left proximal femur, recently transferred to the rehabilitation ward. While admission process was taking place including a revision of the patient’s mobility assessment, patient lost balance and fell while transferring chair to bed. X-ray confirmed another fracture of the left proximal femur and surgery (revision of the patients left total hip replacement) was then required. Admitting house surgeons made aware of the importance of requesting nurse or physiotherapist assistance for mobility assessments. Completed. Falls prevention programme now in pilot phase. In progress. Southland Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up Sentinel 1 1 Wrong site surgery. Patient required readmission and extended stay. No long-term consequences. RCA in progress. Awaiting final report. Serious 4b 2 Baby delivered in helicopter enroute to secondary maternity Patient presented to hospital in pre term labour (scheduled for caesarean Hospital emergency kit to accompany patients during transit, equipment must be accessible at all times. Complete.