Northland District Health Board Serious or sentinel 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. workload management and processes inadequate. Handover processes did not provide relevant information clearly. Revisit medication safety and administration of high-risk for all Emergency Department (ED) staff. Review relevance to ED environment. Review model of care. Formalise handover – use (Situation, Background, Assessment, Recommendation, Response) tool. Revise overload code plan to include staff workload management. All undertaken. Sentinel 4 B&C Unexpected 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 using 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
Waitemata District Health Board Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4D Blood cross-matched for mother (diagnosis of placental abruption) was given to baby in error. Emergency situation at change of shift with multiple teams, resulting in inadequate checking process. No adverse harm to baby. Processes reviewed: requesting blood for a baby emergency call in theatre cord gas in resuscitation situation. Recommendations/ corrective actions implemented. Serious 4D Patient discharged with retained products (placenta) after birth. No ultrasound was conducted prior to discharge. Patient had repeated bleeding with low haemoglobin level of 71. Readmitted with persistent bleeding and plan for further surgery. Experienced a cardiac arrest in operating theatre. Patient fully recovered. Education around ordering ultrasound for retained products if there is repeated bleeding. Completed. Sentinel 4A Patient was discharged in early labour when cardiotocograph (CTG) was misread. CTG was misread by independent midwife. Midwife called and was told that no movements noted since woman had gone home. (Discharge was 11.28am, readmission at 6pm.) Reassessment and fetal death confirmed. All CTGs to be reviewed by a clinical charge midwife (CCM) or a senior medical officer (SMO).
Sentinel 5 Medication administration error. Wrong medication administered. Critically unwell on admission with major cardio-respiratory and other administered medications intended for another patient due to mix-up with prescription sheet. The case has been referred to the Coroner (awaiting confirmed of death). Approved medication administration procedures reinforced with nurses across the DHB. Safe Medicines Steering Group monitors safety strategy initiatives, errors trends and significant incidents. Sentinel 5 Medication administration Small dose was prescribed, but standard dose administered. Prescription misread by the nurse administering medication. Patient unwell with cardio-respiratory 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 (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 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 using emergency algorithms for cardiac arrest and anaphylaxis scenarios. trial
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 bowel wall haematoma. ICU admission. Discharged rehabilitation. Review of rationale with doctor. Reinforce communication with senior consultant. Sentinel 4A Diagnosis It was believed patient had passed products of conception. Misoprostol given to complete miscarriage. Patient presented with vaginal bleeding, and given 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 Keys so staff can readily access toilets in emergencies. New department and procedures reduces risk. New ED department opened in March 2011.
Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as high falls risk. Severe memory impairment. Low blood pressure from medication, low sodium, poor oral nutrition. Serious 6 Inpatient fall resulting in fractured wrist. Assessed as high falls risk. Did not wait for health assistant while showering. Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as high falls risk. Wearing thromboembolic deterrent (TED) stockings. Nocturnal confusion. Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as a high falls risk. Delirium present. Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as high falls risk. Mobilised independently, against advice. Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as high falls risk. Transferring to bed with one assistant. Highly anxious. Slipped. Serious 6 Inpatient fall resulting in fractured Assessed as high falls risk. Mobilised with assistance. Memory impairment. Did not wait for health assistant outside toilet door. Serious 6 Inpatient fall resulting in fractured hip requiring surgery. Assessed as high falls risk.
Auckland District Health Board Auckland DHB advised subsequent to publication of the 2010/11 Serious and Sentinel Event Report that two cases initially reported to the Commission as SSEs had been reviewed, and were reclassified as not being serious or sentinel events. Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4G Child under current care of DHB Early Childhood team admitted with injury. Communication difficulties with Youth and Family Services (CYFS); risk not escalated. Multidisciplinary ‘at risk’ discharge planning and template. Improve process for escalation if plan not followed. Communication standards for CYFS. Ongoing. Serious 1 Patient was administered a platelet transfusion intended for a different patient. No harm, high-risk event. Platelets sent to the wrong destination. Checking process prior to administration was inadequate. Staff education regarding patient identification standards. Simplify documentation and move to electronic ordering of all blood and blood products. Review blood bank layout and check process. Ongoing. Implementation commenced. Complete. Serious 5 Epidural infusion of anaesthetic administered intravenously to a woman in labour. No patient harm, high-risk event. Although colour-coded, epidural and IV connections are inter-changeable. Credentialing/training of inconsistent. Double of correct connection not required. Assess potential for introducing locking system. Revise policy and training to require bedside double-checking of the infusion and connection. In progress. In progress.
Serious 4B Equipment deficiencies during two ward resuscitations: suction system laryngoscope manual ventilation bag. Deaths of two patients involved were not directly caused by these equipment issues, but risk was increased. Suction canister damaged when the bed moved up. Use of plastic bag dust 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 in all inpatient wards. Plastic bags not permitted to 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. does not highlight bolus volume size. No limit for volume on infusion pump. New design paediatric 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 intra-abdominal 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 event. Headache was not usual for subarachnoid bleeding. No 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 wrong 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 bowel 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 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 after 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 prior to division of major structures. Complete Sentinel 4B 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 lungs 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. in place. Serious 6 Fall causing fractured ribs and minor internal bleeding. Fell returning from toilet. Severe underlying medical conditions. Death unrelated to injuries. Serious 6 Fall causing fractured tooth. Child 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 scalp laceration. Dementia. Fell while mobilising without assistance.
Counties Manukau District Health www.cmdhb.org.nz Serious or sentinel code Description of event 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 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 group is investigating ways of modifying internal referral processes for procedures. Serious 1 Gastroscopy procedure was completed on a patient when meant 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 Suite. The Patient Identification is working on a better system for storing and managing labels. A modified World Health Organization (WHO) Time Out procedures checklist has been implemented in Endoscopy. An Endoscopy Quality Group has been established to develop standard operating procedures.
Serious 6 Fall resulting in a fractured arm (humerus). The falls risk assessment was not accurately scored and therefore appropriate interventions not put in place. Serious 6 Fall resulting in fractured ribs. Patient request for assistance to remove anti-embolic stockings was not acted on and patient slipped and fell. Serious 6 Fall resulting in fractured arm (humerus). Falls risk assessment incorrectly calculated and no review of risk after surgery. No interventions in place. Serious 6 Fall resulting in fractured wrist. No interventions put in place for a patient assessed as being at high risk of falling. Serious 6 Fall in Radiology resulting in skull fracture. No requirement for medical radiation technologists (MRTs) to assess patient’s risk of falls prior to radiology procedures. No handover from Emergency Care (EC) to radiology regarding patient’s risk of falling.
Waikato District Health Board Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4B Delay in treatment due to transport problems transporting patient from regional hospital. Consultant-to-consultant referrals from all provincial hospital when needing to activate a transport team. There is no 24-hour seven-day a week onsite CT service. There is currently no centrally transfer role for inter-hospital transfers. There is no central air transport service, no contractual requirements re air service, no central co-ordination, no budget; plane/helicopter providers are responsible for their own maintenance. This is a rare/complex clinical condition. There is no clear documented pathway within Waikato DHB of how patients with this condition in a non trauma situation are managed. Discussion to at clinical directors’ forum regarding consultant-to-consultant referral as this in not a one-business-unit issue. When criteria agreed a memo to come out of Chief Medical Advisor (CMA) office to all provincial hospitals (not Waikato DHB rural facilities), advising of new requirement. Undertake a retrospective audit of time of referral and time of actual scan for after-hours patients (after 4pm) (approx 50 cases over a three-month period). Presentation of that data to Management Executive Committee and action plan to be developed to address any issues identified. Implement the inter-hospital transfer project. No action plan developed as this is a national This risk to be added to the organisation risk register/plan. needs to be a standard approach to how patients with this condition are managed. Inter-hospital project in progress.
Serious 4G Patient pulled out intravenous line, which led to death. Critically ill, confused, patient bled to death because his femoral central venous line was pulled out. The patient had a history of pulling out lines and the patient required restraint. Inadequate assessment of the risks for this patient was undertaken at the receiving ward, and inadequate documented plan of care for the management of the patient’s confusion, history of pulling lines and presence of a central venous line. Death referred to Coroner who decided not to investigate further. Review how critically unwell, elderly confused patients are managed in acute settings – this action included in the Delirium project. Review handover and transfer process whereby patients transferred from areas with high nurse: patient ratio to areas with lower nurse: patient ratio. Formalise the handover process between health professionals as part of the Hospital at Night project. Random by two Nurse/Midwife Directorate members to critically analyse a set of patient records and provide feedback to the charge nurse where this is inadequate or incomplete. Serious 4B Senior doctor responsible for patient was not informed of deteriorating patient condition. Patient died later in day. The practice of not rostering specialist medical staff on the night duties resulted in consultant not being called to review patient. Changes made to roster to ensure specialty medical are on call. Completed. Serious 4B Failure to diagnose/ recognise unstable patient. Misinterpretation of patient’s clinical signs and symptoms led to patient being clinically managed as a stable rather than an unstable patient. Document for management of trauma cases to be updated in required format. Implementation plan to include education and ongoing education and orientation. To re-assess ED medical staff number against expected norm for other equivalent EDs.
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 after 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 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 staff 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 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 Patient fell earlier in day and no corrective actions taken to minimise, thus patient fell again later. project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and fractured hip, which 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 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. Rapid 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 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 falls mobilised without supervision. Falls project completed and new risk assessments and education in place for staff Completed
Sentinel 3 Patient had retained swab following cardiac procedure. Required additional procedure to remove swab. Patient’s procedure did not stop when incorrect count was notified to the team. Review implementation process of the Waikato DHB policy: Surgical for Swabs, Sharps and Instruments. Discussion to take place regarding implementing a ‘Time Out/Stop’ command when incomplete count is notified. If agreed, this action to be added to Surgical Count for Swabs Sharps and Instruments policy. Implement the WHO Surgical Safety Checklist in department. The operating surgeon should also verbally acknowledge they have the scrub practitioner . Sentinel 1 Surgical procedure performed on wrong patient due to two patients’ biopsy samples being mixed up, and incorrect diagnoses for both patients involved. Ineffective quality control processes being in place/implemented and environmental issues led to biopsy tissue belonging to Patient B being placed in Patient A cassette during laboratory process. This resulted in patient having surgical procedure meant for another patient. Review laboratory process/work flow (in consultation with Waikato DHB process specialist). Review the current quality monitoring and reporting systems within laboratory and implement any recommendations. Initiate creation of a regional networking quality model (with a focus on learning/sharing of best practice) for this laboratory. Revise/produce procedure documentation regarding independent double checks on biopsy specimens. Review practice of processing like specimens (eg, breast) through laboratory. Review options for technical and managerial leadership structures in this laboratory.
Taranaki District Health Board www.tdhb.org.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 1 Wrong 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 chest X-ray result was not noted. The patient’s 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.]
Sentinel 4A 15-month delay in diagnosing lung cancer. Palliative treatment undertaken and patient died several months later. Chest X-ray taken prior to dental surgery showed a lung lesion. Patient presented to ED with pain, lesion was larger and had spread (metastisised). No copy of X-ray report sent to GP. Previous chest 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 scale 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 6 Patient fell from beside bed, resulting in hip fracture. Palliative care patient assessed as a very high risk. All appropriate falls risk minimisation measures instituted, including bell mat alarm. Alarm sounded, staff responded immediately but patient had already fallen. There was a delay in informing the family of the event. Patient was placed on constant supervision. All made aware of the Whanganui DHB’s Open Disclosure policy and timely communication with families. Completed. Centre for Patient Safety will monitor compliance with the Open Disclosure policy. Serious 4 A Delay in responding to deteriorating patient post-operatively. Patient required further extensive bowel surgery and transfer to a tertiary facility Intensive Care Unit. Junior medical did not escalate their concerns to senior medical staff. Nursing did not follow the early warning score protocol and notify the Duty Nurse Manager about the patient’s condition. Once the deterioration was recognised the patient’s vital signs were closely monitored; however, not all recordings were documented. Tutorial held for junior medical staff to improve communication competency. The surgical team have conducted ‘recognition of the acute abdomen’. Requirements of Health Records Policy and documentation standards reiterated to all Completed. Completed. Audit six-monthly.
Bay District Health Board www.hawkesbay.health.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Sentinel 6 Fall resulting in fractured hip. Patient died three days post fall. Falls risk assessment completed and falls prevention strategies incorporated into care plan. Staff member left patient unsupported for a short period of time. In-service education to include falls minimisation. Hospital project expanded scope of responsibility for falls minimisation to be Sentinel 6 Fall resulting in fractured hip and arm and head injury. Patient died 23 days post fall. Falls risk assessment completed and falls prevention strategies incorporated into care plan. Fall result of impulsive behaviour. Aspiration pneumonia a contributing factor to death. No recommendations. Sentinel 4A Failure to identify maternal and fetal deterioration during labour. Infant died several hours after birth. Failure to recognise deteriorating condition. Miscommunication between independent midwife and medical staff. Fetal monitoring training for staff. Review clinical responsibility between independent midwife and hospital team. Review methods of communication with patients and between clinical staff. Referred to the Coroner. Education completed. Policies and procedures reviewed, including communication methods. Awaiting Coroner’s findings. Serious 4G Delayed diagnosis due to failure to schedule appointment within required timeframe. Patient waiting greater than expected time for colonoscopy. Patient postponed for more urgent case. Review management of endoscopy waiting list systems and processes. Full clinical and administration review of waiting list completed. Access criteria developed. Resources reviewed. Waiting times improved.
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 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 in-depth 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 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 6 Inpatient fall resulting in scalp laceration and fracture of hip. Patient fell while walking from toilet to hand basin. Staff not present when fall occurred. Falls risk assessment was completed on admission. Serious 6 Fall resulting in fractured wrist. Patient mobilising independently. Had a shower and reached for towel and lost balance. Fell to the ground and used wrist to break fall. Falls risk assessment completed on admission and was not assessed as a risk. All appropriate steps taken. Serious 6 Fall whilst an inpatient resulting in skin and fractured hip. Fall occurred when patient was getting out of bed and used chair to assist with standing. Chair moved and patient fell to the ground. Unwitnessed fall. Patient had been assessed as a falls risk and was confused. Serious 6 Fall resulting in fracture of hip and increased hospital stay. Patient assisted to toilet. When patient turned to sit on toilet, leg gave way and patient fell to the ground twisting leg. Patient was on assisted walking and toileting. Serious 6 Patient fall resulting in fractured hip. not observed. Unable to accurately define when fracture took or how the event occurred. Serious 6 Patient fall resulting in fractured hip. Patient had been independently mobilising with low frame. Assessed as nil falls risk prior. Patient fell whilst moving from frame to toilet seat.
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 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 staff 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 found 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.
Sentinel 11 Patient death 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 of procedure (angiogram). Patient deterioration and death. Concerns regarding and level of care. Review in progress.
Serious 4C Stillbirth following induction at 39 weeks 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 fetal 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.
West District Health Board www.westcoastdhb.org.nz Serious or sentinel 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.
Sentinel 4G Death of a baby (twin) following emergency caesarean section. Review completed. Causal findings around the need for a more comprehensive programme of adjustment and orientation for Obstetric Specialists to the rural environment, the need for a local guideline for the management of twins to assist staff when unexpected events occur, the absence of multidisciplinary training in Greymouth to facilitate communication between disciplines in complex clinical situations - may have resulted in staff not effectively sharing their knowledge of local procedures, not questioning decision making nor suggesting the use of additional procedures/equipment. The induction process for new medical staff is reviewed and adjusted to ensure there is suitable orientation to the facilities, support services and to the likely impact of these on clinical practice Ensure best evidence guidelines specific to the WCDHB are developed, disseminated and available within the unit on; electronic fetal monitoring - including mention that where continuous fetal monitoring is indicated but unable to be obtained, Fetal Scalp Electrode (FSE) should be used the management of twin labour and delivery – including delivery in theatre for all twins A course specifically to improve management of obstetric emergencies is run at the WCDHB as a way of improving multidisciplinary teamwork between Obstetricians, Midwives, Anaesthetists, Duty Nurse and Midwife Managers etc That consideration is giving to transferring women with multiple pregnancies to a tertiary centre at an appropriate gestational age.
Sentinel 4D A planned removal of the gall bladder was complicated by a bowel perforation. The patient died unexpectedly 11 days later. Root analysis review completed. Report in draft. Serious 4D Patient’s wound drains were removed prematurely, requiring a return to the operating theatre to have the drains reinserted under general anaesthetic. Patient was cared for in another surgical specialty ward post-operatively where staff were less familiar with the care of breast surgery patients. Instructions with regards to drain removal were misunderstood. Continue review of surgical bed requirements and ensure the issues surrounding this event be made known to the group reviewing surgical bed requirements. Action under way. Serious 5 Concentrated potassium was administered as a bolus without resultant harm. Incorrect administration of concentrated potassium. No concentrated potassium will be held in any clinical area. Action under way. Serious 8 Mental health inpatient absconded from care. Potential for serious harm. No preventable causal factors identified. No recommendations. Serious 11 A severe (stage 4) pressure injury developed during episode. Timing issues/delays occurred in the reporting of the pressure injury and ordering and provision of equipment. All staff to complete revision of pressure area assessment and prevention, including the use of pressure-relieving equipment. Actions under way Serious 11 A severe (stage 4) pressure injury developed during inpatient episode. Timing issues/delays occurred in the reporting of the pressure injury and ordering and provision of equipment. All staff to complete revision of pressure area assessment and prevention, including the use of pressure relieving equipment.
Serious 4D A baby unwell at delivery later died. Despite many advances remain significant limitations with respect to the usefulness of ultrasound to predict actual or imminent fetal compromise in late pregnancy. This meant that the degree of antenatal compromise in this pregnancy was not recognised. There was inadequate senior medical officer (SMO) supervision of care. No one SMO took responsibility for making a plan of management and communicating the history and that plan to the team on Birthing Suite. There was no systematic obstetric SMO involvement in the induction process. More senior obstetric opinion may have increased the awareness of risk and the priority for rapid delivery once events unfolded. The current classification system for caesarean section does not provide a sufficiently clear indication either of urgency or of clinical indication. As a result, neonatal staff and some staff in Birthing Suite and Birthing Suite Theatre were not certain of the urgency regarding delivery nor the reason for that urgency. This may have increased the interval from decision to delivery and may have compromised staffing at baby’s resuscitation. All women who are admitted to the maternity ward for observation in the antenatal period should be reviewed by an obstetric SMO on a regular basis, ideally at least twice per week. The SMO must oversee care and formulate a coherent management plan and where appropriate communicate this to colleagues. In all cases where there are suspected maternal or fetal risk factors the decision for induction of labour should be reviewed by an obstetric SMO. The current maternity unit ‘Induction of Labour’ guideline will require review and amendment to reflect this recommendation. SMOs should be involved at all steps of the induction process where such additional risk factors are identified and a logical plan for induction should be made by the obstetric SMO. A classification system for caesarean section leaves no room for misinterpretation of urgency is required. The classification system will indicate the need for a member of the neonatal team experienced in advanced resuscitation. On introduction of this change, appropriate staff education should take place. Development of a for new neonatal RMOs on requesting anaesthetic support. Improved processes for neonatal resuscitation training. Actions under way. Serious 6 Inpatient fall sustaining a broken hip. The Clinical Board is providing a leadership role to progress the vision of having zero harm from falls. All SAC 1 & 2 falls are
Canterbury District Health Board www.scdhb.health.nz Serious or sentinel 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 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. Falls 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 Board www.southerndhb.govt.nz Serious or sentinel Event code Description of 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 point 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 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 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.
Serious 6 Inpatient fall resulting in a fractured hip. The 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 falls, 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 way. Sentinel 11 Inpatient death 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 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. 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 staff 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 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 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 (femur) 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 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. 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 audit to be completed of all observation charts and medication charts to identify compliance with PCA protocol. Review of the management and communication of patients 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 there is less contact with other vulnerable patients. Serious 4C Unrecognised patient deterioration due to inadequate monitoring. Investigation under way. Serious 5 Medication involving a higher dose of opioid being administered, resulting in patient being treated in the high dependency unit. Incorrect dose of opioid prescribed resulted in the administration of five times patient’s normal dose. Patient charted 37mL instead of 37mg. Correct opioid dose not reconciled with patients usual prescriber. Immediate Hospital Safety 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 4C Delay in monitoring and response to the coagulation status of the patient may have contributed to bleed in brain (subarachnoid haemorrhage) and patient death. Root cause analysis being undertaken. Recommendations not finalised at time of reporting. In progress. Serious 4A Delayed radiological diagnosis resulting in paralysis. Diagnostic error highlighted where spinal lesion missed on CT scan undertaken. Not identified until subsequent MRI taken to diagnose back pain and leg weakness. Full disclosure and apology to patient and family. ACC treatment injury completed. Departmental audits undertaken. Completed. Serious 4E Delay in receiving radiological diagnosis leading to disease progression of bladder cancer. Referral prioritised incorrectly as non-urgent. Examination completed 10 months post referral. Review of Medical Imaging referral process completed. Recommendations for improvement currently being implemented. Wait list managed back within guidelines of six to seven weeks. Completed. Serious 4E in diagnosis of cancer. Root cause analysis undertaken finding issues with the handling of abnormal scan results. Review medical staff orientation, Explore system to flag all abnormal results. In progress. Serious 6 Inpatient fall resulting in fractured hip. Patient mobilising with distant supervision following clinical assessment in preparation for discharge, and fell. Falls programme introduced. Completed.