Northland District Health Board Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 5 Patient misidentification resulted in wrong patient receiving medication. Omission of patient identification checks during medication administration. Staff workload management and processes inadequate. Handover processes did not provide relevant information clearly. Revisit medication safety and administration of high-risk drugs for all Emergency Department (ED) staff. Review relevance to ED environment. Review model of care. Formalise handover – use SBARR (Situation, Background, Assessment, Recommendation, Response) tool. Revise overload code plan to include staff workload management. All undertaken. Sentinel 4 B&C Unexpected birth at home. Unclear communication between ambulance officers and hospital staff, baby requiring unanticipated admission to intensive care unit. Inadequate communication occurred between the health professionals involved in the care pathway; this had the potential to impact on the overall outcome. Inadequate documentation. SBARR – Situation, Background, Assessment, Recommendation, Response – (or equivalent) utilised to convey handover information. Single set of clinical notes. Consider opportunities for multiagency neonatal resuscitation education. the ED ambulance call record to meet the need of the maternity services. Reinforce the use of the emergency call system in hospital to seek any emergency assistance. Handover is structured by standard documentation on delivery suite. Protocols are easy to access, both electronically and in hard copy. Flow chart developed for use with the ambulance radio. Monthly Basic Life Support updates including emergency call processes. trial
Sentinel 5 Medication administration Wrong medication administered. Critically unwell on admission with major cardio-respiratory and other Nurse administered medications intended for another patient due to with prescription sheet. The case has been referred to the Coroner (awaiting confirmed cause of death). Approved medication administration procedures reinforced with nurses across the DHB. Safe Medicines Steering monitors safety strategy initiatives, errors trends and significant incidents. Sentinel 5 Medication administration error. Small dose was prescribed, but standard dose administered. Prescription misread by the nurse administering medication. Patient unwell with major and other co-morbidities. Due to very limited cardiovascular reserve this single dose was associated with circulatory failure, which was unresponsive to treatment. The case has been referred to the Coroner (awaiting confirmed cause of death). External expert review of investigation undertaken. Review of practice for verbal communication of unusually small (or large) prescriptions to reduce the risk of misreading error. Implement national medication chart with pre-printed decimal point. Communication processes between clinical teams under review. Recommendations being implemented. Safe Medicines Steering Group monitors safety strategy initiatives, errors trends and significant incidents. Serious 5 Medication prescription error. 1mg of intravenous Adrenaline prescribed and administered for patient having an anaphylactic (allergic response) event. Adrenaline 0.5mg intramuscular injection should have been prescribed and administered. Patient experienced significant rise in blood pressure. Transferred to intensive care unit (ICU). Cardiac impact noted. Patient has had no long-term adverse effects. Review of emergency protocols with doctor and nurses and competence update. Review of 777 (emergency) call procedure with junior staff. Training exercises emergency algorithms for cardiac arrest and anaphylaxis scenarios. up respiratory
Serious 4B Inappropriate procedure performed. Abdominal ascites tap performed despite ultrasound stating no free fluid present. Deteriorated overnight with increasing abdominal pain and hypotension from wall haematoma. ICU admission. Discharged after rehabilitation. Review of rationale with doctor. Reinforce communication with senior consultant. Sentinel 4A Diagnosis error. It was believed patient had passed products of conception. Misoprostol given to complete miscarriage. Patient presented with vaginal bleeding, and Misoprostol to 'complete miscarriage'. Ultrasound showed a live fetus with fetal bradycardia (slow pulse). Patient given activated charcoal within 12 minutes of being given Misoprostol. Later scan showed a non-viable pregnancy. Policy written for ED staff over the use of Misoprostol. Staff education undertaken. Recommendations implemented. Serious 4C Attempted suicide. Cleared for discharge with family by Mental Health team. Requested to go to the toilet, and found cyanosed and unconsciousness. Emergency action taken. Difficulty monitoring mental health patients in previous department. Risk assessment reviewed with staff. Keys given so staff can readily access toilets in emergencies. New department and procedures reduces risk. New ED department opened in March 2011.
Serious 4B Equipment deficiencies during two ward resuscitations: suction system laryngoscope manual ventilation bag. Deaths of two patients involved were not directly caused by equipment issues, but risk was increased. Suction canister damaged when the bed moved up. Use of plastic bag dust cover can dislodge suction. Difficult re-assembly of suction unit. Older laryngoscope style with risks of loss of locking pin, loose light bulb, and incompatible blades. Checking and restocking of resuscitation and emergency trolley is inconsistent. Revise suction canister height at the bed-space in all inpatient wards. Plastic bags not permitted to cover suction canisters. High quality laryngoscopes to be brought to ward resuscitations, rather than kept on ward trolleys. Full revision of resuscitation tray, trolley and checking/re-stocking process. In progress. Implemented. Implemented. Revision complete; roll-out of new system in progress. Sentinel 4B Remotely monitored patient sustained cardiac arrest. Probable delay in resuscitation; influence on fatal resuscitation outcome not clear. Delay in advising ward; coronary care staff called unattended ward phone. Ward staff unfamiliar with response systems. Inadequate communication with family. Change to calling co-ordinator cellphone rather than ward phone. Standard messages/phrasing to be used when Code is called from Coronary Care Unit (CCU). Review of bereavement processes and resources. Implemented Implemented Organisation -wide programme in progress Serious 4C Delay in emergency response for uterine perforation after termination of pregnancy. Delayed recognition; poor communication; inadequate physiologic monitoring. Unfamiliarity with emergency call systems due to historic independence of service. Protocol for suspected or actual uterine perforation. Standardised post-operative physiologic monitoring. Staff education and training on emergency call systems. Complete. Implemented. Complete. operative
Serious 5 Excessive sedative dose for an infant undergoing a radiology procedure, causing coma for 24 hours. Poor communication between ward and radiology regarding use of sedation. Paediatric sedation policy to be reviewed and updated. Development of a checklist for the wards. Handover guidelines between wards and Radiology staff. Completed In progress In progress Serious 5 Infant received 10 overdose of intravenous fluids. Required additional treatment but no adverse effects. Incorrect prescription not detected. Chart does not highlight bolus volume size. No limit for volume on infusion pump. New design paediatric fluid prescription and administration chart. Use of infusion pump software. In final stage of development. Implemented. Serious 4D Three-month delay in liver biopsy performed without review of appropriateness when patient unwell and at high risk. Post-procedure major bleeding. Overdue procedure not identified. No clinical review prior to procedure. No IV access constrained treatment when bleeding occurred. Alert system in radiology information system (RIS) for overdue prioritisation requests. Escalation process for review of elective procedures when patient condition has changed. Standardise practice: all patients having solid organ cutting needle biopsy to have IV access. Not possible with current system. Ongoing. Implemented. Sentinel 4A Delayed diagnosis of major pressure area of a patient under district nursing care in the community. Subsequently died from severe infection. Treatment was focused on the lower leg ulcers. Complex patient, no multi-disciplinary or long-term holistic care plan. Revise district nursing supervision Revision of assessment form to be more comprehensive including information. Identification of all complex patients and assignment of primary nurse. Implemented.
Serious 4A Missed diagnosis of ‘sentinel’ bleed prior to large brain (subarachnoid) haemorrhage three days later. No long-term harm; high-risk Headache was not for subarachnoid bleeding. No other diagnostic tests performed. Policy change: Emergency medicine specialist review required to confirm discharge without further investigation for atypical headache presentations. Implemented. Serious 5 Heparin infusion (anticoagulant) incorrectly increased to 80ml/hr during minor surgery, causing significant bleeding. Confusion between multiple pumps. Unfamiliarity with volumetric pumps. Use of infusion pump ‘smart’ software. Implemented. Sentinel 4A 14 months for an urgent (<8 weeks) appointment in the eye clinic. Patient now legally blind. Booked into incorrect clinic. Administrative procedures for incorrect clinic attendance unclear. Referral sent to DHB twice. Central Referrals Office to ‘colour code’ clinics as a means of clinic identification. Written guideline for process for patients presenting to the wrong clinic. Regional issue to be discussed with neighbouring DHBs. Completed. In progress. In progress. Unclear 10 Delay in transferring baby from referring DHB. Death possibly preventable by earlier transfer. Inadequate communication and handover. Infectious status conflict with clinical urgency. Electronic register and tracking system for referrals. Referrers advised of thresholds for escalation. Review infection control guidelines. In development. In progress. No change required.
Serious 4D Perforation of uterus during gynaecological surgery with injury requiring further surgery (rectal resection, hysterectomy and temporary ileostomy). Surgical technique used (Microwave endometrial ablation technique) caused full thickness uterine burn. Scheduled for surgical audit. Awaiting review. Serious 1 Child flown from another DHB for an unnecessary CT scan under general anaesthesia. Future booking for CT scan had not been cancelled urgent surgery had been required, making the scan unnecessary. Modification of booking system to require review and re-confirmation of future outpatient bookings after inpatient admissions. Organisation-wide – under review. Serious 4D Injury to upper lobe of lung during surgery (resection of lower lobe), eventually requiring complete removal of left lung. Misinterpretation of intra-operative test Reduced visualisation from surgical approach Surgical Re-confirmed the need for absolute certainty of anatomy to division of major structures. Complete Sentinel 4B Four-month delay in treatment for cancer as clinical staff unaware of unexpected findings on histology report. Surgical audit form completed without histology available. No system to ensure histology results are reviewed after patient discharge. No mandatory escalation process for unreviewed histology reports. Important unanticipated abnormal histology results not highlighted. Reinforce standards with surgical registrars. Mandatory electronic escalation system for unsigned reports. Retrospective sign-off process for all unaccepted histology reports – automatic 2009 or earlier, manual 2010 onwards. Reduce/eliminate reports. Review reporting systems with pathology and information systems. Completed. In process with regional IT provider and individual services. In process. May incorporate into e-Lab development.
Sentinel 4D Aspiration of feed into due to dislodgement of naso-gastric tube. Patient died despite appropriate treatment. Nasogastric feeding uncommon on this ward. Partial tube removal by patient not identified. Increase awareness in nursing staff around best practise with naso-gastric feeding. Commencement of bedside handovers. Naso-gastric Resource Nurse appointed. Completed. Serious 6 Fall causing fractured upper arm and intracranial (brain) bleeding. Unobserved fall out of bed. Rails in place. Serious 6 Fall causing fractured ribs and minor internal bleeding. Fell returning from toilet. Severe underlying medical conditions. unrelated to injuries. Serious 6 Fall causing fractured tooth. fell in play area of Children’s Emergency Department. Serious 6 Fall causing facial fracture and intracranial (brain) bleeding. Unobserved fall from bed with rails while awaiting X-ray. Serious 6 Fall causing fractured upper arm. Unwitnessed fall when going to toilet. Serious 6 Fall causing spinal fractures. Confused patient left ward and fell outside hospital. Serious 6 Fall causing fractured hip. Confused. Fell while mobilising without assistance. Serious 6 Fall causing laceration. Dementia. Fell while mobilising without assistance.
Serious 6 Fall causing fractured hip. Fell mobilising without assistance. Serious 6 Fall causing fractured wrist. Unobserved fall from low bed. Serious 6 Fall causing fractured nose. Unobserved fall trying to get out of bed. Bed rails not in use. Serious 6 Fall causing opening of surgical wound. Fall while exercising in gym unsupervised. Serious 6 Fall causing fractured wrist. Fell while getting to walker. Did not seek assistance. Serious 6 Fall causing intracranial bleeding. Tripped over mattress on the floor in mental health unit. Serious 6 Fall causing intracranial (brain) bleeding. Fell while attempting to get out of bed unaided. Serious 6 Fall causing dislocated hip. Previous hip replacement. Fell while attempting low seating position. Serious 6 Fall causing facial laceration. No known falls risk. Fell while returning to ward from outside hospital. Serious 6 Fall causing scalp laceration. Confused. Fell trying to get out of bed unassisted. Serious 6 Fall causing fractured hip. Fell while self-mobilising to commode. Death from underlying terminal disease.
Serious 6 Fall causing fractured upper arm. High risk. Self-mobilised against instruction while staff were attending another patient. Serious 6 Fall causing scalp laceration. Fell while self-mobilising against instructions. Serious 6 Fall causing facial laceration. Unwitnessed fall in toilet. Serious 6 Fall causing intracranial (brain) bleeding. Fell while being assisted to toilet. Serious 6 Fall causing fractured sacrum (lower spine). High falls risk. Mobilised without assistance against instruction. Serious 6 Fall causing fractured hip. Dementia. Fell while mobilising without usual assistive aids. Serious 6 Fall causing large scalp laceration. Unwitnessed fall in toilet. Serious 6 Fall causing fractured hip. No known falls risk. New onset urinary incontinence. Slipped on wet floor. Serious 6 Fall causing fractured hip. Unsupervised fall when going to toilet. Serious 6 Fall causing facial fractures. No falls risk. Unwitnessed fall. May have tripped on bedside table. Serious 6 Fall causing fractured hip. High falls risk. Mobilised without assistance against instruction. Serious 6 Fall causing fractured ankle. Fainted being mobilised by physiotherapist.
Counties Manukau District Health www.cmdhb.org.nz Serious or sentinel Event code Description of Review findings Recommendations/actions Follow-up Serious 1 CT scan performed on patient in error. Name label mistakenly attached to another patient’s CT request form. Review process of storing patient identification labels and develop interventions to improve safety of system. Investigate the potential for electronic requests for procedures. A Patient Identification Group has been established to review incidents involving misidentification of patients. This group is currently working on better systems for storing and managing labels. An electronic solution is not currently feasible, but is likely to be developed in the next 24 months. The is investigating ways of modifying internal referral processes for procedures. Serious 1 Gastroscopy procedure was completed on a patient when for another patient. The patient then required a second procedure to reinsert a stomach tube (nasojejeunal tube) resulting in a gastric perforation. Name label mistakenly attached to another patient’s form due to: practice of storing patient identification labels for multiple patients in a single location process of writing most referrals at the end of the ward round absence of a clearly defined process, defined roles, use of ‘Time Out’ in establishing patient identity. Review process of storing patient identification labels and develop interventions to improve safety of system. Develop and implement a Gastroenterology Procedural Checklist. Develop standard operating procedures for Gastroenterology Intervention The Patient Identification Group is working on a better system for storing and managing labels. A modified Health Organization (WHO) Time Out procedures checklist has been implemented in Endoscopy. An Endoscopy Quality Group has been established to develop standard operating procedures. trial
Serious 1 Patient was scheduled for a bronchoscopy. Patient consented for and received a gastroscopy in Absence of a clearly defined process for checking and confirming patient identity and indications for the procedure with the patient prior to sedation. No clearly defined processes for consenting patients who have English as a second language. Implement the Time Out before procedure/sedation checklist. Review of consenting process in the Endoscopy Unit for patients who have English as a second language. By the end of July 2011, 1200+ staff had received education on formal identification of patients – this was done in conjunction with: updating policy and procedure roll-out of a standardised method of face-to-face engagement with patients and whānau roll-out of the modified World Health Organization Time Out procedures checklist in Endoscopy. Serious 4A Treatment delayed for a patient with severe chest pain resulting in the patient sustaining significant cardiac damage. Because the test for heart damage (troponin) was negative, the severe pain was not recognised as being potentially cardiac in origin and care was not escalated. electrocardiogram (ECG) signs of an anterior myocardial infarct (heart attack) were not initially recognised by nursing and medical staff. The patient was discharged home following treatment. Multidisciplinary governance group to be set up to manage issues relating to management of the ‘patient at risk’. Ward staff to be up-skilled in management of acute coronary syndrome and the basic interpretation ECG changes. Training session for house surgeons on anterior myocardial infarct and interpretation of ECGs. A multidisciplinary ‘patient at risk’ governance group has been set up. Education and training for nursing staff on the ward is ongoing. A training session was given to house surgeons by a senior medical officer (SMO) and will be ongoing as part of the annual orientation programme for the new house surgeons intake.
Serious 4B Treatment delayed in a patient with a severe stroke who deteriorated and subsequently died. Nursing staff did not recognise changes associated with deterioration in a patient with a severe stroke and did not document observations overnight. It is unlikely this would have changed the outcome for this patient. Variations in staff understanding about when and how often neurological observations should be undertaken in the neurologically compromised patient, including triggers for action. Education and training regarding patients who may have this pathology. Institute regular formal competency assessments for all nursing staff within the stroke ward to ensure maintenance of clinical skills with regard to using the Glasgow Coma Scale (GCS) to assess neurological status. Training package around assessing neurological status using the GCS has been developed. This includes an to be completed prior to a face-to-face competency assessment. This training will be implemented on the ward and also included in an organisation-wide orientation package. Serious 4B After surgery, a patient was not discharged on a blood thinner (Enoxaparin) as planned, and was readmitted with a blood clot (pulmonary saddle embolism). No permanent harm. There was no mechanism in place to ensure all discharge instructions are completed and/or checked off prior to the patients discharge. Enoxaparin prescriptions are not included on the discharge medications prescription as it is customary practice to dispense from the patient’s ward. Develop a standardised discharge checklist and pilot in Surgical Services with a view to possible roll-out across the organisation. Review the organisational process of dispensing Enoxaparin and develop an organisation-wide flow A standardised discharge checklist was developed and piloted in Surgical Services. A working group is being developed to consider possible roll-out across the division and then the organisation. A review of the organisational process for dispensing Enoxaparin was completed. Flow charts and posters were developed and placed in all medication areas. The pharmacy website was updated with new information.
Serious 10 Delay in treatment due to transport problems transporting patient from regional hospital. Patient died. Review under way. [HQSC comment – subsequently advised by DHB SSE report went to printing that case not an SSE] Serious 4G Patient died on ward shortly after admission from ED. Review way. Serious 4A Delay in diagnosis of cancer due to failure to follow up results. Patient has subsequently died. Review under way. Serious 4D Patient suffered complications during surgery and required further surgery. Review under way. Serious 4B Communication breakdown between services resulted in delayed treatment for patient. Patient has since had appropriate management and treatment. Department staff unaware of the requirement to contact the requesting clinician if a significant change to a result or diagnosis is made. Department currently have no process of recording these notifications/ conversations in the patient’s clinical record. Department will contact requesting clinician directly to advise of significant change. Develop a process for recording this communication in the clinical record. Department to adjust format of report sent so that if further work is being done to confirm diagnosis this will be clearly documented in report.
Serious 4B Delays in referral and treatment of patient. Patient developed problems and required toe amputation. Lack of processes in place to manage these high-risk patients. Process to be developed for return of care of patients to Diabetes Podiatry service. [Waikato DHB subsequently stated that, following further review, this case was not a serious event. However, this advice was received after the SSE report was completed, and this case is included in the data within the main report.] Serious 4B to treat abnormality leading to patient developing cervical cancer. The process for checking and ensuring patient’s details are correct was not carried out. Share learning about this incident with all clinical and administrative staff, eg, at staff meeting. Emphasise the practice of checking patient details and updating of patient label and information on clinical records during each visit to ensure information current and correct. Mandatory use of electronic system for such details. Check and refresh patient details during each visit to ensure information current and correct. Audit of this compliance to take place.
Serious 6 Patient fell and fractured hip. Surgery required and patient deteriorated following surgery and died. Patient mobilised independently without supervision. learning of this event with nursing and medical staff including implication of practice about management of the specific needs of a confused elderly patient with physical limitations and in an unfamiliar environment of a hospital. Implement the falls management practices to area Ongoing Completed Serious 6 Patient fell whilst mobilising independently. Condition deteriorated and patient died Patient while in a confused and disorientated state pushed a table aside, mobilised independently and fell. As a result of this incident the following actions were taken: all tables fitted with brakes ward continues to and evaluate different equipment resources to minimise falls, including current use of exit alarms and pressure mats/cushion. falls project completed and new risk assessments and education in place for staff. Completed. Completed. Serious 6 Patient fell and hit head. Condition deteriorated following fall and patient died The patient was not sufficiently stable on feet, due to clinical condition Falls project completed and new risk assessments and education in place for staff. Audits completed to ensure compliance with falls assessment requirements. Completed. Completed. Serious 6 Patient fell and fractured hip. Required surgery. Condition deteriorated after surgery, and patient died. No root causes found. Other learning needs identified: Review knowledge of care planning process and timely/accurate completion of documentation – including the process of handover/completion of information between shifts. Serious 6 Patient fell from bed and sustained a head injury and died. All appropriate actions pre and post fall were taken. Review supervision of compromised patients whilst in bed.
Serious 6 Patient fell and sustained fractured shoulder. Patient later died from unrelated events. Patient fell whilst standing from commode. project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and fractured ankle. Patient was not compliant with medical treatment, due to other medical conditions. Medical team to discuss with Mental Health team as to future management of patient in ways that will allow required medical management. Completed. Agreed plans in place for ongoing care. Serious 6 Patient fell and fractured hip requiring surgical repair. Unpreventable fall. Review identified that all appropriate actions pre and post fall were taken. No recommendations. Serious 6 Patient fell mobilising and fractured shoulder. No surgical intervention required. Inadequate care planning and management of specific needs of a confused elderly patient with physical limitations and other medical problems in an unfamiliar environment of a hospital. Falls project completed and new risk assessments and education in place for staff. Serious 6 Patient fell and fractured hip. Surgical repair required. Patient with confusion mobilised and fell. Falls project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and required surgical repair of lacerations sustained in fall. Patient with limited mobility mobilised and fell. project completed and new risk assessments and education in place for staff. Completed.
Serious 6 Patient fell and sustained fractured hip. Patient lost balance when closing the bathroom door. Patients will be supervised with their mobility for the first 48 hours of admission regardless of level of independence. Completed. Serious 6 Patient fell and fractured wrist. Patient fell earlier in day and no corrective actions taken to minimise, thus patient fell again later. Falls project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and fractured hip, required surgical repair. Patient assessed as requiring assistance mobilising walked alone and fell. Falls project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and sustained head injury (sub arachnoid haemorrhage). Patient with fluctuating confusion and decreased mobility attempted to mobilise unaided. Patient was known to be high risk for falling and was on increased watch. Patients who are able shall have meals in the dining room with one staff member present at all times. nursing rounds are conducted Mon-Fri and identify that fall risk assessment is carried out per procedure. Completed. Completed. Serious 6 Patient fell and fractured hip, requiring surgical repair. Review in progress. Serious 6 Patient fell resulting in her sustaining a fractured wrist. Patient stood up from chair and fell. Increased supervision for patient. Use of lap belt identified as appropriate for this patient. Completed. Completed. Serious 6 Patient fell and sustained fractured skull. Patient with history of falls mobilised without supervision. Falls project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and sustained head injury. Patient with history of mobilised without supervision. Falls project completed and new risk assessments and education in place for staff Completed
Serious 6 Patient fell and dislocated pelvis bone. Patient mobilised independently without supervision. project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and fractured shoulder. Patient had medical condition that likely contributed to fall. Introduction of escalation flow chart to expedite transfers to medical wards and consistency of information used to assess requirement for general hospital admission. Completed. Serious 11 Patient’s cardiac arrest not noticed as alarm did not activate in theatre. Patient died later in ICU from other causes. Review concluded that no issue with alarms. Active resuscitation was initiated within seconds of arrest being noticed. Referred to Coroner. No root causes found. Completed Serious 12 Elective admission to hospital. Patient developed flu in hospital and died. Review concluded no issues with care provided. Consideration is given to extending the hospital flu vaccination programme to offer the flu vaccine to high-risk patient groups. Completed. Sentinel 1 Patient had procedure (PICC Line – peripherally inserted central catheter – inserted) that was for another patient. The patient identity was not verified by two members of staff to ensure correct patient was transferred to radiology. To develop a policy on patient identification. Policy to have implementation plan agreed as part of process. To develop a patient verification handover process process to include patient not to be transferred until process is completed. Process to include phone verification checks. To implement the WHO Surgical Safety Checklist for Radiology Interventions Only process. Completed
Serious 4A Two patients’ biopsy samples were mixed up resulting in incorrect diagnoses for both patients involved. As above. As above. Serious 11 Patient assaulted a third person whilst being transported to hospital by family. Review completed. Scheduled for panel 2012. Serious 11 Patient attempted self-harm and sustained minor injuries. Observation levels were not clearly communicated or promptly enacted. Service user was not sighted by morning staff at commencement of shift. New RN not aware RNs can increase level of observation without medical officer approval if risk identified. Clarity on observation procedure given to all ward staff and confirmation of responsibility for handover between shifts. Handover procedure has been amended to including the requirement for staff to sight all service users immediately following handover. All new nurses to have identified preceptors and training to be provided to increase number of available preceptors. Training continues through 2011 and preceptorship and available preceptors are monitored via the Clinical Nurse Director and Clinical Governance Forum. Completed March 2011 April 2011. Ongoing. Serious 11 Self-harm resulting in injuries. The immediate management and communication of identified escalating risk directly following assessment, was not adequate.. Review the Levels of observation procedure to include: The communication and management plan process between staff, directly following assessment indicating increased risk. Ongoing
Serious 9 Unwitnessed assault on an inpatient by co patient. Sustained multiple injuries resulting in permanent disability. Risk assessment and management plan appropriate. Nil recommendations made. Referred to Police. Serious 4D IV drug leaked into tissue, requiring surgery. IV cannula insertion difficult as patient having a fit. IV protocol including flushing line was followed and the line was deemed patent. As the patient was suffering a fit, the line was secured with a bandage, thus unable to observe. Two hours later, the IV site was checked and leak was discovered. Feedback to nursing staff on Phenytoin infusion (drug to treat fit) and selection of IV insertion site. Completed. Serious 6 Inpatient fall resulting in fractured shoulder. Elderly patient who required assistance to mobilise got out of bed to go to bathroom, without calling for assistance. Sentinel 6 Inpatient fall resulting in subsequent death. Appropriate assessment made but still fell. The apparent cause of the fall was multi-factorial, and not necessarily attributed to a single cause. Sentinel 6 Inpatient fall resulting in fractured hip and subsequent The fall was not the root cause of the death. No formal falls risk assessment undertaken. Reporting requirements not met.
Tairawhiti District Health www.tdh.org.nz Tairawhiti DHB has adopted the Severity Assessment Code (SAC) rating terminology in accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with ‘Sentinel’ and ‘Serious’ events. The SSE report stated that Tairawhiti had six SSEs. Following review, one of these cases was the suicide of a community mental health and addiction services patient in the community, so should not have been included in the overall numbers. Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 6 Fall causing injury to eye and subsequent loss of vision in that eye. Inconsistent communication processes for patients attending the Day of Rehabilitation Unit (DRU). Clinical did not accompany patient to the DRU. Out-dated falls policy and hence varying understanding of falls risk. DRU nurse vacancy. Revise the handover process between inpatient wards and the rehab unit and consider handover sheet. Visual of identifying patients at risk of falling in line with new Falls Policy. Clinical to accompany patients to the rehab unit. Implement revised Falls Policy. Training regarding falls risk and prevention provided to all levels of staff who care for at risk patients, at orientation and updates thereafter. Vacancy filled. policy reviewed and implemented, including: new falls risk form and identification stickers as an easy communication method to identify patients at risk of falling handover between ward 9 and DRU standardised clinical notes accompany patients attending DRU.
Sentinel 4C Neonatal death and maternal haemorrhage. Chorioamnionitis with Group B strep infection after prolonged induction. Intrapartum asphyxia. Failure to correctly interpret CTG tracing and respond appropriately. Overall deteriorating clinical situation was not appreciated. Intrapartum Fever” guideline including” presumed chorioamnionitis” developed. Approved and released August 2011 CTG training Majority of staff completed K2 training New staff to complete K2 training in 1st month Plan to link regionally with RANZCOG training and aim to achieve all Midwives and O&G Consultants attending Quality Meetings Weekly MDT Clinical Quality meetings to review CTG’s, discuss clinical cases and to encourage open communication between Midwives and O&G Consultants. Serious 5 Patient collapsed during sedation. RCA in progress. Conscious sedation guidelines are under review.
Taranaki District Health Board www.tdhb.org.nz Serious or sentinel code Description of event Review findings Recommendations/actions Follow-up Serious 1 patient anaesthetised (son rather than father, with same name). Both father and son had exactly the same name and contact details. Son was registered on the local Patient Management System with his National Health Index (NHI) number but the father was not. Son had symptoms that correlated with his father’s surgical diagnosis. Son had recently been returned to his mother’s care and displayed symptoms that led her to believe that her son was already on the wait list. The surgical referral form did not contain the patient’s NHI number. The identification of the signee on the consent form (ie, patient, parent or guardian) was not marked. The procedure for adding a patient to the surgical waiting list was not followed. Ensure that all referrals have the patient’s NHI number and date of birth clearly documented. Ensure that when discussing consent with the patient, the consent form is completed, including the identification of the signee. Ensure staff read all referrals thoroughly and not accept/enter any referrals that are not completed appropriately. Reminders given to staff. Referral documents are to be reviewed at and anaesthetic assessment appointments. Discussion to occur between the contracted provider hospital and the DHB to identify where streamlining can occur. All completed
Serious (cont’d) 1 (cont’d) Wrong patient anaesthetised (cont’d). (cont’d) The son’s referral document was not available and not sighted at clinic. At the anaesthetic appointment, the consent/referral form was not viewed. Staff member competent in the referral onto the surgical booking list process. The surgical booking team had undergone significant changes including reorganisation of work allocation, staff turnover, increased workload and added pressure while recruitment occurred. Serious 4A Delay in diagnosis and treatment for lung cancer that was visible on a chest X-ray taken in July 2008. The discharge summary was not completed. The Clinical Management of Test Results and Investigations procedure was not followed. Failure to arrange follow-up specifically related to the chest X-ray result. When admitted for the operation, the patient’s previous X-ray result was not noted. The patient’s chest X-ray result and advice concerning follow-up was not communicated to the patient or noted in the patient’s discharge summary to the patient’s GP. Sending copies of all X-ray results to the patient’s GP commenced in 2009. Digital radiology commenced in 2009, allowing easier access to X-rays. The Clinical Management of Test Results procedure has been reviewed and is now a policy. Responsibilities have been clearly communicated. Explore options where information technology can assist clinical staff with results management to improve robustness. Explore options for reviewing X-ray results that have not been ‘marked as read’ prior to 2009 and implement the best solution. Completed. Completed. Completed. In progress. In progress. Serious 4B Patient presented with back pain that was diagnosed 48 hours later as an epidural abscess. Reviewing neurosurgeon to review the case notes and determine whether there are any actions to be taken to prevent delay in diagnosis. Report pending. [Commission comment: Advised by Taranaki DHB after report printed that this case, following review, was not considered a serious or sentinel event.]
Serious 5 Patient found unconscious after administration of morning medications, which patient should not have been prescribed, and required transfer to CCU. Patient made a full recovery. Patient admitted to the Day Unit. Medicine reconciliation did not before patient’s surgery. RMO prescribed medications from patient’s own medication card, however, the medications had been discontinued some time ago. All medications should be checked and written on a medication chart prior to transfer to the ward from the day unit. If this cannot be completed, then medications may have to be withheld and the patient monitored until medicine reconciliation is completed. Education regarding blood pressure and anti-hypertensive medications to be conducted. Pharmacy staff to monitor. Conducted. Serious 4B Failure to make outpatient appointment resulting in a delay in treatment. Electronic discharge summary stated outpatient appointment to be made in one week; however, this was not written in the ‘follow-up appointments to be made’ section, and was overlooked by administration staff. An audit of discharge summaries showed inconsistency in recording follow-up appointments. Tutorial for RMOs on the correct use of the follow-up section of the electronic discharge summary. Ongoing. Serious 6 Admitted to surgical ward, as a blistery rash had developed under a leg plaster. While mobilising in the ward, patient fell and fractured a hip, requiring surgery. No evidence of written or verbal instructions given by clinic regarding plaster care and symptoms to look out for. No falls risk care plan implemented on admission. Written copy of patient care instructions must be to patient prior to discharge. All verbal instructions given to patient must be listed in patient notes. All staff on the surgical ward to have an understanding and awareness of the new Falls Injury Prevention Standard by 1 April 2011. Template for instructions developed March 2011. New falls risk assessment tool introduced and end of bed falls care plan implemented April 2011.
Sentinel 4A 15-month delay in diagnosing lung cancer. Palliative treatment undertaken and patient died several months later. X-ray taken prior to dental surgery showed a lung lesion. Patient presented to ED with chest pain, lesion was larger and had spread (metastisised). No copy of X-ray report sent to GP. Previous X-rays not reviewed. Patient’s GPs to be sent a copy of all reports generated from the dental unit. Previous chest X-ray films/reports must be viewed when an abnormality is detected. Completed. Ongoing. Serious 5 Medication given in incorrect order, resulting in patient experiencing temporary paralysis prior to procedure in theatre. Patient traumatised by the event. Order of Theatre list was changed at short notice due to a hole in the instrument wrapping being detected. This resulted in the patient not being mentally prepared and it was thought there was no time to administer a Anaesthetic medications drawn up and syringes were labelled; however, incorrect syringe used. Patient known to be anxious on previous occasions and this was not adequately responded to by staff. Develop a flow chart for premed options including timeframes and patient presentation. Replace sterile tray shelving units to allow for better storage of sterile trays. Consider protective devices for corners of instrument trays to prevent inadvertent piercing of sterile packing. Introduce red-barrelled syringes for paralysing agents. Research and implement anxiety rating scale to accurately identify patients’ anxiety. Review Pre-operative Checklist. Include section for anxiety rating and notification of who the patient wishes information to be given to such as next of kin/support person. Benchmarking with other DHBs is recommended. Completed. Audit in six months for compliance. Under way. Implement and audit in six months for compliance.
Serious 4B Delayed diagnosis and treatment due to failure to act on abnormal radiological findings. Abnormal X-ray findings not followed up. GP name not entered in radiology system until after report finalised. Review guideline for routine investigations. Review sign-off process for abnormal radiology results. Ensure GPs are always assigned in the radiology system so they receive a copy of the finalised report. In progress. Serious 4A Delayed diagnosis due to failure to schedule radiology procedure and delayed radiology reporting following the procedure. Shortage of radiologist resource. Implementation of new electronic radiology system resulted in patient report delays. Increase/recruit radiologist resource. Develop and implement clinical indicators/flags for monitoring CT colonoscopy waiting times. Additional radiologist employed. Electronic radiology system implemented. Reporting volumes are being monitored. Serious 4A Procedure and reporting delay resulting in delayed diagnosis.
MidCentral District Health www.midcentraldhb.govt.nz Serious or sentinel Event code* Description of event Review findings Recommendations/actions Follow-up Serious 4A Fall resulting in fractured ankle prior to admission. Diagnosis delayed by four weeks. Fracture occurred prior to admission during cardiac arrest when patient fell at home. Was missed by staff for four weeks until patient began mobilising. immediately ordered and fracture noted. Colour, warmth and movement, and sensation assessments to be completed early where potential bony injuries identified. Completed. Sentinel 4C Patient found dead during morning round. No causal factors were identified in this incident. Regular overnight checking was completed, however more inspections are required. Review the observation policy and procedure for the detail of the inspection process that is required overnight. Completed. Serious 4D A haemodialysis machine was not disinfected prior to connection to patient. No identified harm to patient. The process flow for the management of dirty to clean machines was not clear and was impacted by inadequate storage space. Strengthen standards for process and flow of cleaning haemodialysis machines. Identify additional storage space to have clean and dirty machines separated. Completed. Serious 5 Incorrect dose of Methadone administered. 10 times correct dose of Methadone given (ie, 50ml instead of 5ml) as a result of the unfamiliarity with medication. Intensive monitoring of patient was required. Review and strengthen medication checking process in specialist units when staff are unfamiliar with medication. Explore options for obtaining lower strength medication (ie, 1mg/ml). Completed. Serious 3 Part of a surgical instrument left in abdomen following surgery. Subsequently the patient was returned to theatre for removal of the retained instrument part. An additional instrument was brought into theatre during the surgery and was not added to the count. Revise and strengthen process to ensure all instruments used in surgery are included on count lists. Completed.
Serious 5 A 14-month old child was administered too much intravenous fluid during a procedure under general anaesthetic, resulting in increased inpatient stay. Fragmented communication and handover re child’s hydration status. No agreed interdepartmental process related to perioperative management in acute paediatric patients. Strengthen clinical handover process with a primary focus on the documented information, from Child Health to Anaesthetics. Completed. Serious 5 Chemotherapy intravenous medication administered to the wrong patient, resulting in increased inpatient stay. The process for preparing, storing and checking of chemotherapy medication was not followed and did not provide clarity around this process. Chemotherapy protocols to be standardised. Develop process to track chemotherapy medication delivery and administration. Completed. Serious 5 One unit of frozen plasma given in error. Existing protocols for checking of blood components prior to administration were not followed. Audit compliance with protocols. Ensure all staff complete mandatory update on blood component administration protocols. Completed. Sentinel 2 Suspected suicide while on day leave from inpatient unit. There was incomplete risk assessment documentation leading to gaps in knowledge regarding the patient’s risk levels. There was also lack of clarity regarding leave processes for voluntary patients. Leave form to be adjusted to include a process for voluntary patients. Assessment of mental status to be documented on leave form. Completed. Serious 3 Gauze swab missing from count at end of procedure. Patient examined and swab not found. Abdomen closed and X-ray performed. Swab identified in abdomen therefore patient required further surgery to remove swab. Portable X-ray machine not available in theatre before patient’s abdomen was closed. Taken to X-ray after surgical closure and swab identified. No recommendations made. Completed.
Sentinel 6 Patient fall. Subsequently found to have fracture. Patient died following surgery to repair fracture. Patient admitted with significant and poor prognosis. Assessed as moderate risk on admission. During admission falls risk increased and 15-30 minute check protocol implemented. Patient had surgical repair of fracture on day after fall. Surgery successfully completed, but patient condition deteriorated post operation; died three days after the fall occurred. Fall ‘hot-spots’ mapping under way as part of hospital-wide Falls Prevention Project. All falls documentation and effectiveness of same under review. incidence and prevention standing agenda item at ward meetings. Falls Prevention Project ongoing and added to organisation wide key performance indicators. Progress monitored on a quarterly basis by Patient Safety Leadership Group. Serious 6 Patient fall resulting in fracture. Patient fell whilst independently transferring from chair to bed. Review completed. sensor pad trialled with patient – this worked well following event and will be extended for other patients. Falls prevention project ongoing and added to key performance indicators. Progress monitored on a quarterly basis by Patient Safety Leadership Group.
Capital & Coast District Health Board www.ccdhb.org.nz From 1 July 2009, Capital and Coast DHB stopped using the terminology ‘serious’ and ‘sentinel’ and adopted Severity Assessment Code (SAC) rating terminology in accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with “Sentinel” and “Serious” events. Serious or sentinel Event code Description of Review findings Recommendations/actions Follow-up Serious 11 Patient self-harm. Police involved in response. The review concluded that appropriate actions and decisions were made in respect of the management of the patient. The review did not make any recommendations. Not applicable. Closed. Serious 4B Child seen twice on same day at hospital clinic. Transferred to hospital emergency department on second presentation. Patient died in Intensive Care Unit later that day. Meningococcal septicaemia. Review found that care provided by the hospital clinic was appropriate. Review identified a delay in the administration of antibiotics due to the transfer time from the clinic to the emergency department. Review recommended the hospital clinic protocol be amended to specify that antibiotics be given in the clinic to any patient suspected to be suffering from meningococcal septicaemia. Review also recommended that the DHB apologise to the family for the delay in administration of antibiotics. Referred to Coroner at time of event. Coroner decision not to open an inquiry. Coroner reconsidering need for inquiry at request of family. The Paediatric Service and hospital clinic have revised the protocol for antibiotic administration. Report and apology provided to family. Serious 4B Significant deterioration of existing pressure area during hospital admission. Review found that while overall care was appropriate and the pressure area was at high risk of deterioration, some aspects of communication of wound care assessment and management were not consistent and not escalated when indicated. Review recommended an education plan to develop further on pressure area management and wound expertise, the development of a process for management of complex wounds and strengthening of communication between inpatient areas and community nurses. The education plan and the process for management of complex wounds were developed and implemented and communication processes between inpatient and community nurses strengthened. Closed.
Sentinel 11 Apparent intentional removal of vascular catheter by patient. Despite emergency response the patient died. Review that the action by the patient could not have been predicted and that staff had acted appropriately when the incident occurred. Review did not make any recommendations Referred to Coroner at time of event. Coroner decision not to open an inquiry. Serious 4B Patient admitted due to a complication one day after having had insertion of a tube into the stomach (Percutaneous Endoscopic Gastrostomy tube – PEG). The tube was removed four days later (delayed removal). The patient died later that day. Review found that while a delay had occurred in removing the PEG, the patient’s care was appropriate and there were no significant clinical concerns about the PEG remaining in place until the equipment was available. The review team did not consider that the delay contributed to the outcome. Review identified that the delay occurred because the type of PEG tube had not previously been used in the department and specialist equipment for removal was not immediately accessible. Review recommended that a formal process for the introduction of new equipment to the service be developed and implemented and that a check be completed to ensure all necessary equipment is stocked. A process has been developed and implemented for the introduction of new equipment to the service. A patient education brochure has been developed at the request of the patient’s family and is available. Closed. Serious 4B Patient presented with bronchial carcinoma. It was identified that a chest X-ray taken two years previous showed an opacity and recommended further investigation. Review identified that the radiology report was communicated to the patient’s GP and that a clearer process for direct communication of such results should be developed as there was a lack of clarity as to who was following up the result. Review recommended informing the primary provider of the event and outcome of DHB review, ensuring the patient had been informed, and development of a more robust system for communication and follow-up of reports. The primary provider was informed and subsequently confirmed that the patient had been informed. Work is in progress to strengthen the system for communication and follow up of reports of unexpected findings on chest x-ray.
Serious 4C Patient deterioration. Concern that there was a delay in transfer to the Intensive Care Unit. Patient died. Review found patient’s treatment was in keeping with clinical guidelines, although in hindsight earlier transfer to Intensive Care should have been undertaken. Review endorsed the DHB’s existing implementation of an Early Warning Score Chart and mandatory Medical Emergency Team call system for predetermined parameters. Review also recommended that the service agree the most appropriate pathway for the care of complex patients experiencing deterioration; and to consider whether the Patient at Risk team should have the ability to directly request the opinion of an Intensive Care doctor where they are concerned regarding patient management. Referred to Coroner at time of event. The Early Warning Score Chart and the mandatory Medical Emergency Team call system have been implemented. The service has agreed the pathway for the care of complex patients. The Patient at Risk team are able to contact the ICU registrar or consultant at any time if concerned about a patient’s condition. Serious 4B & 5 Unexpected patient death following anticoagulant treatment for suspected heart attack (non-STEMI myocardial infarction). Review found that the main factor that contributed to the patient’s death was the decision to treat the patient for a non-STEMI myocardial infarction (heart attack) on the basis of Troponin T test results. Review also noted that double the intended dose of anticoagulant was prescribed and given as a first dose due to human error, and that an algorithm included in guidance related to a new high sensitivity Troponin T test may contribute to the risk of such an event. Review recommended development of organisation wide guidelines for the diagnosis and treatment of myocardial infarction (heart attack) and that the guidelines be developed and agreed between the emergency, cardiology and internal medicine services. It was identified that the had not been referred to the Coroner at the time. Coroner subsequently notified. Development of the guideline is under way.
Sentinel 11 Patient in community. Patient had been admitted that day for suspected deep vein thrombosis (DVT – clot). The patient had been allowed short-term leave to return for ultrasound scan. Patient died a few hours after taking leave. Review found that the patient’s assessment was fully completed and the appropriate treatment pathway was commenced prior to the leave. The decision to allow the leave was based on established practice of treating such patients on an outpatient basis. The review team consider this patient received appropriate care and did not identify any deviation from usual practise. The review team concluded that the DVT pathway is appropriate and supported by current practice and no modifications were required. The review made no recommendations. Police referred to Coroner at time of event (as death occurred in community). Serious 4F Patient required Medical Emergency Team call upon arrival in ward after transferring from the Emergency Department. Review in progress. Serious 4B Patient admitted within 24 hours of procedure (angiogram). Patient deterioration and death. Concerns regarding and level of care. Review in progress.
Serious 4C Stillbirth following induction at 39 gestation. Review identified that the cardiotocograph (CTG – baby’s heart tracing) reading was not reassuring and indicated the need to review and change the plan of care. Review did not conclude that the adverse outcome could have been averted and noted that the opportunity for intervention may have been missed. Review recommended review of service education and practice related to cardiotocograph interpretation. The report was provided to the family and a subsequent meeting held to discuss the report. Regional approach to training in progress and planned roll-out of cardiotocograph/Fetal Surveillance Education Training Passport for relevant staff at CCDHB in place. Serious 4C Patient developed paraplegia resulting from epidural haematoma during epidural infusion therapy. Review identified a five-day delay in identification of the patient’s loss of lower limb sensation and implementation of appropriate treatment, during which time the patient developed permanent paralysis. During this period changes were initially attributed to the epidural infusion. Review recommended an apology be made to the family, the epidural policy be amended, staff education to learn from the event and review of existing documentation to specify action required when any unusual or persistent sensory or motor deficit is present. The report was provided to the family and a subsequent meeting held to discuss the report. The Ward Advanced Analgesia Observation Chart and ICU Observation charts have been modified. Policy and staff education actions are in progress. Serious 5 Prolonged bradycardia (low fetal heart rate) due to a bolus dose of syntocinon during labour that resulted in the woman requiring an emergency caesarean. The review team identified that the mother received a bolus of syntocinon due to a human error in the set-up of the syntocinon infusion through a pump. Review recommended and practice change related to syntocinon administration. The report was provided to the family. Syntocinon Infusion Policy updated including specific process for checking and pump set up. Staff refresher education re Management of Healthcare Incidents/ Open Communication Policies completed.
Nelson Marlborough District Health Board www.nmdhb.govt.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4B A 42-week gestation infant developed breathing difficulties during transfer to the postnatal ward. Avoidable upper airway obstruction. Review the discharge and transfer process between the recovery area and postnatal ward. Ensure that orderlies are utilised for transporting the patient during transfer enabling the escorting midwife to care as required in line with NMDHB policy for internal transfer of patients. Review of postpartum care following delivery to afford continuity of midwifery care to mothers and infants. District-wide policy review to provide guidance for midwives regarding appropriate supervision of mother and infant whilst breastfeeding during transfer, especially if mother affected by sedative medication. Review the appropriateness of the number and placement of resuscitaires and consider the need for permanent placement in theatre/recovery area. Serious 6 Patient sustained bilateral wrist fractures as a result of a fall on an inpatient unit. The patient died several days later of an unrelated cause. The patient’s fall was an unforeseeable incident. Appropriate assessment and intervention occurred specific to the patient’s mobility needs. Nil.
West Coast District Health Board www.westcoastdhb.org.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Sentinel 4B Death of a baby following emergency caesarean section. Review underway. Report awaited. Serious 4B Mother transferred to Christchurch by ambulance following birth was suffering from eclampsia on arrival. Report completed. The patient had been medically cleared for ambulance transfer without escort. While it appears that a clear process for assessment and transfer occurred in this instance, there are no written guidelines regarding transfer of mothers post delivery, nor guidance around when a midwife escort is appropriate. A comprehensive handover be provided to appropriate CDHB staff for all maternity related transfers. To support the process for mothers post delivery, a guideline be developed based upon the current document ‘Guidelines for transfer of Maternity Care, Secondary – Tertiary’, this to include guidance as to when a midwife escort is appropriate.
South Canterbury District Health Board www.scdhb.health.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 5 Patient prescribed incorrect medications resulting in a significant deterioration in patient’s physical condition. The patient made a full recovery. Correct medication reconciliation process was not followed. Standardisation of process and confirmation requirements for medication reconciliation with community and hospital pharmacists established. Action plan developed and monitored. All action points progressing with planned roll-out of medicines reconciliation across all inpatient services in 2011. Serious 6 Resident fall in hospital level dementia unit, resulting in fractured hip. Independently mobile resident sustained a fractured hip. Fracture surgically repaired. Serious 6 Patient fall with no obvious injury until two days later when swelling and X-ray revealed a fractured leg (tibial plateau). Falls risk assessment completed and fall prevention plan in place. Serious 6 Patient fall resulting in serious wound to leg. Falls risk assessment completed on admission and falls prevention plan in place, including requirement for supervision when mobilising. Patient attempted to mobilise independently.
Serious 6 Patient fell from bed. No obvious head injury noted on examination. Two hours later patient found to be unresponsive and subsequently died. Referred to Coroner. risk assessment completed on admission and falls prevention plan in place; however, management guidelines relating to monitoring patients following a fall were not followed resulting in a failure to detect the deteriorating patient. Serious 6 Patient fell, sustaining a fractured arm. Falls risk assessment completed on admission and falls prevention plan in place.
Southern District Health www.southerndhb.govt.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Sentinel 2 Voluntary patient committed suicide while on overnight leave. No clear single point of contact for the patient’s family and rostering of nursing staff means the primary nurse is only intermittently available. The long-term high risk of suicide for this patient was not documented. Only short-term clinical risk was regularly noted. Although the patient’s firearms were removed from his possession he was able to use his firearms licence to purchase a new gun. A single contact for family with a member of staff likely to be consistently available. Review of the current risk documentation practices. Discussion take place between Southern DHB mental health services and the NZ Police about the removal of firearms licences during significant episodes of depression and the pathway to reinstatement of firearms licences when full recovery has occurred. Risk Management Working Group formed to review the service approach to risk assessment and management of clinical risk. A draft revised treatment plan for inpatient areas is currently under consultation, part of which aims to improve the recording and of clinical risk observations and regularly changing leave status. Serious 6 Inpatient fall resulting in laceration to inner forearm. Falls prevention strategies were appropriate and supervision during activity was of a high standard. All reasonable steps had been taken to keep the patient safe while permitting return to maximum independence. Staff are now more aware of the hazard and will consider the potential risk when assisting or supervising patients’ mobility in areas where linen trolleys are located. Sentinel 2 Inpatient suicide. Investigation under way.
Sentinel 3 Retained central line guide wire following a complex central line insertion, requiring removal in radiology. This was a complex insertion required two central line packs to be used, resulting in the first wire accidentally being left in place. The standard technique for inserting central lines is the ‘Seldinger’ technique which is a well-established procedure in clinical practice used to introduce catheters, probes, electrodes, etc. into vessels. As the task is unable to be changed, the intensive care unit has educated all the staff who might be involved in any central venous line insertion to maintain vigilance to ensure that the wire is removed – particularly if two or more kits are used. Serious 3 Retained surgical swab following a pacemaker insertion. Swab found during another surgical procedure. No policy in place within the setting by which the attending doctor is required to advise the scrub nurse/circulating nurse that an open wound is/has been ‘packed’ with a gauze swab. No policy within the setting enabling and requiring an instrument, sharps and/or a swab count to be undertaken when an open wound procedure is undertaken. The swabs used in the cardiology laboratory are not radio-opaque and therefore cannot be identified upon ultrasound or X-ray imaging. The potential for a retained product producing an inflammatory response does not have a mechanism for investigatory escalation. Requirement that all medical officers undertaking pacemaker implantation (or any other procedure involving an open wound) to advise the scrub nurse/circulating nurse of an intention, or the act of, placing a gauze swab (or any other temporary item) within the wound pocket. Implement the Main Operating Theatre Surgical Count Policy in this area. All swab material to contain a opaque marker. When a surgical site demonstrates signs of infection, and/or inflammation, and/or oedema, multi-view X-rays of the site are performed for the purpose of excluding the possibility of retained equipment. Cardiology Dept now has radio opaque gauze and all standard gauze has been removed. Swabs (and all other equipment used) are counted and documented as per the surgical count policy. Patient X-rayed during procedure which would highlight any remaining gauze.
Serious 6 Inpatient fall resulting in a fractured hip. The falls prevention plan was developed and followed to best care for the patient. Consideration was given to the residential context the patient was being discharged to and hence the falls alarm was discontinued just prior to the fall. Protective hip pads, although not able to prevent the risk of could minimise the risk of fractures resulting from falls. The use of alarms should be continued as long as a high risk of falls exists and their use can be justified. Consideration should be given to the purchase of hip protector pads to decrease the likelihood of a fall resulting in a hip fracture. Serious 4B Management of mother in labour in the community requiring urgent treatment. Investigation under way. Sentinel 11 Inpatient subsequent to taking Methadone obtained illegally. Possibility that the patient obtained Methadone for recreational use while on approved ward leave. Patient did not present with early warning signs of Methadone toxicity, therefore patient was only observed every 30 minutes overnight according to protocol. Mental health staff to have education from the community alcohol and drug service about the high risks associated with recreational methadone use. The Co-existing Problems Working Group will consider the inclusion of methadone toxicity as a subject in the development of the upcoming education. A fact sheet on methadone toxicity be developed for patients identified as current or potential illicit methadone users. Co-Existing Problems Working Group is meeting regularly and attention is being given to the development of a broad skill set among MH staff which will include addiction issues.
Serious 6 Inpatient fall resulting in fractured knee. Falls prevention risk planning was not completed prior to the patients fall; however, the physiotherapist had assessed the patient as being safe to independently mobilise Documentation standards and expectations to be reinforced to via the charge nurse managers and educators on falls prevention and care planning. Ongoing of the falls prevention programme to ensure it is being utilised correctly. Serious 5 Intravenous cross contamination of a medicine (Fentanyl) between two patients. The Fentanyl syringe was not discarded at the end of the duty and was subsequently used on another patient. The Intravenous Medication Policy was not correctly followed. Education sessions held for all staff to reinforce the principals of the IV policy and to provide instruction on correct discarding of controlled medications. Controlled medication cupboard checks will be undertaken to ensure any leftover medications are discarded according to policy at the end of each shift. The education session focused on ensuring practice change was occurring and to provide a question/answer session for staff queries and options on how to work within the scope of the policy. Sentinel 11 Inpatient death. Awaiting findings from the coroner as it appears this death may have been due to natural causes. Serious 6 Inpatient fall resulting in a fractured leg requiring surgery. Patient subsequently died. The patient was treated as high risk according to the falls prevention protocol and the fall was multi-factorial. It does not appear that the fall contributed to the patient’s death. All available preventative measures were in place therefore there are no recommendations. Serious 8 Patient absconded and an alleged assault occurred. Investigation way.
Sentinel 4F Delayed access to emergency treatment in remote site prior to urgent transfer resulting in patient death. Investigation under way. Serious 3 Retained surgical instrument (clamp) following gastric bypass surgery requiring subsequent surgical removal. Investigation under way. Sentinel 4A Misdiagnosis resulting in patient discharge and subsequent death due to rupture of major abdominal artery (aorta). The patient’s presenting complaint was of back pain. Misdiagnosis and discharge occurred despite thorough examination. Delay in radiology reporting which may have identified the condition. Current back pain proforma does not include rupture of abdominal aorta as part of the diagnosis as it is a rare cause. A process to enable consultant involvement in decision making regarding discharge from the Emergency Department (ED). Establish a process to ensure timely review of X-ray findings for ED patients. Consider adding rupture of abdominal artery to the current proforma with guidance on potential for misdiagnosis.
Serious 4C Unrecognised patient deterioration due to inadequate monitoring. Patient was subject to decreased respiratory drive possibly due to sedatives given and it is possible there was a primary aspiration event which compromised the patient’s ventilation. The respiratory depression was treated and the patient recovered. Patient-controlled analgesia protocol not followed. The patient’s ongoing pain management plan was deactivated by the Hospital Pain Team. A ward to be completed of all observation charts and medication charts to identify compliance with PCA protocol. Review of the management and communication of patients under both long-standing and acute medical teams. Serious 9 Inpatient assaulted by another inpatient requiring emergency treatment. Patient who assaulted was appropriately treated and protection of others was managed by limited access to the ward with tight controls to ensure others’ safety, however this patient’s level of aggression was unpredictable. The patient, as much as is practical, be managed in the community setting where there is less contact with other vulnerable patients. Serious 4C Unrecognised patient deterioration due to inadequate monitoring. Investigation under way. Serious 5 Medication error involving a higher dose of opioid being administered, resulting in patient being treated in the high dependency unit. Incorrect dose of opioid prescribed which resulted in the administration of five times patient’s normal dose. Patient charted 37mL instead of 37mg. Correct opioid dose not reconciled with patients prescriber. Immediate Hospital Safety Alert disseminated to always prescribe liquids in milligrams because of the different strengths available. Use of this medicine requiring medicine reconciliation be part of prescribing policy and included in orientation for all medical staff. Nursing staff are to administer liquid medications only if prescribed in milligrams. Pharmacy currently reviewing medication policy.
Sentinel 4D Cardiac arrest of ventilator-dependant patient during MRI scan. Equipment became disconnected during transfer. The incident was well managed with a successful outcome. Anaesthetic Specialist, Registrar and Technician education regarding the equipment utilised in this and other environments in Radiology. Continuing ongoing advanced life support education be undertaken by all Anaesthesia and ICU staff. At least once yearly educational visits as part of departmental teaching to maintain familiarisation with this environment. Serious 6 Inpatient fall resulting in fracture of pelvis. Investigation under way. Serious 6 Inpatient fall resulting in fractured knee. Investigation way. Sentinel 4F Death of a child with complex underlying health conditions, which may or may not have been prevented by earlier admission to the Intensive Care Unit. Baseline oxygen saturations when patient was well were not available for reference. Resuscitation status was not clearly documented. Paediatric Early Warning Scoring System (PEWS) not currently in use, but is under development for use in South Island DHBs. Children with chronic conditions should have baseline oxygen saturations recorded at intervals when well. Children with complex medical problems presenting with acute illness should have their resuscitation status reviewed in discussion with family/whanau and clearly documented. PEWS to take place on the children’s ward. Sentinel 4D Inadvertent misplacement of a nasogastric tube resulting in patient death. Investigation under way. In the interim an organisational risk alert has been circulated to inform staff of the potential risks of this procedure. Serious 6 Inpatient fall resulting in fractured hip. Investigation under way.