Serious 5 Potential Patient administered Delivery of poor prognosis to patient Develop training module for Advance Care Plan 1 overdose of insulin to himself without support in place. medical and nursing relating coordinator to be appointed after receiving a poor to bad news’, including for a one-year period. ‘sharing Ward round made without nursing or prognosis by medical team. providing patient support. Responsibilities will include allied health staff and no handover Appropriate countermeasures educating staff about after round. Conversation with End of life discussion and taken. sharing bad news, grief patient not documented clearly. decisions to be clearly counselling, conducting documented. family meetings and enacting advanced care planning directives. Serious 5 2 10 x overdose of medication Poor design of medication chart for Redesign medication chart to Medication chart writing dose. incorporate decimal point for redesigned to facilitate documenting dose. correct interpretation of Poorly written prescription was not dose. validated or challenged. Safe prescribing initiative. Safe prescribing initiative Shortage of ward pharmacist. Develop business proposal to and business proposal increase staff. Automated medicines dispensing underway. cabinet does not have safety Investigate software to enhance System enhanced but not software to alert re overdose. system to alert re overdose. yet tested or implemented. Serious 5 2 Penicillin related medication Failure to recognise medication was Clinical pharmacist to review Medications reviewed. given to patient with penicillin related. medications that contain Posters developed and documented allergy to penicillin with staff. placed in all clinical areas. penicillin resulting in Develop posters which lists anaphylactic reaction commonly prescribed drugs requiring urgent treatment. containing penicillin. Clinical pharmacist to review good prescribing practices with doctors. Serious 5 2 Patient received Medical staff at DHB 1 not able to Urgent meeting to be held Meeting held. Agreed login chemotherapy in two different readily access pertinent information between providers to facilitate to be given to senior DHBs resulting in side about patients attending other DHB access to DHB electronic records doctors. effects. for treatment. This has been an for senior doctors. Steps in place for regional ongoing issue. document reviewer to cover all DHBs by mid-2010.
Serious 5 Potential 1 Patient administered overdose of insulin to himself after receiving a poor prognosis by medical team. Appropriate countermeasures taken. Delivery of poor prognosis to patient without support in place. Ward round made without nursing or allied health staff and no handover after round. Conversation with patient not documented clearly. Develop training module for medical and nursing relating to ‘sharing bad news’, including providing patient support. End of life discussion and decisions to be clearly documented. Advance Care Plan coordinator to be appointed for a one-year period. Responsibilities will include educating staff about sharing bad news, grief counselling, conducting family meetings and enacting advanced care planning directives. Serious 5 2 10 x overdose of medication Poor design of medication chart for writing dose. Poorly written prescription was not validated or challenged. Shortage of ward pharmacist. Automated medicines dispensing cabinet does not have safety software to alert re overdose. Redesign medication chart to incorporate decimal point for documenting dose. Safe prescribing initiative. Develop business proposal to increase staff. Investigate software to enhance system to alert re overdose. Medication chart redesigned to facilitate correct interpretation of dose. Safe prescribing initiative and business proposal underway. System enhanced but not yet tested or implemented. Serious 5 2 Penicillin related medication given to patient with documented allergy to penicillin resulting in anaphylactic reaction requiring urgent treatment. Failure to recognise medication was penicillin related. Clinical pharmacist to review medications that contain penicillin with staff. Develop posters which lists commonly prescribed drugs containing penicillin. Clinical pharmacist to review good prescribing practices with doctors. Medications reviewed. Posters developed and placed in all clinical areas. Serious 5 2 Patient received chemotherapy in two different DHBs resulting in side effects. Medical staff at DHB 1 not able to readily access pertinent information about patients attending other DHB for treatment. This has been an ongoing issue. Urgent meeting to be held between providers to facilitate access to DHB electronic records for senior doctors. Meeting held. Agreed login to be given to senior doctors. Steps in place for regional document reviewer to cover all DHBs by mid-2010.