Equipment-related events # Provider Summary of event Root causes Recommendations Actions taken 8 St John A technology failure of The fault occurred in a Complete Infrastructure Regularly maintaining network switches resulted in cluster of outdated network as a Service (IaaS) and supporting the in the loss of the majority of switches. project will remove all current technology. critical operations vulnerable equipment and Escalation procedures applications and related provide a highly are in place to manage functionality within the tolerant computing patient and business Clinical Control Centre in environment. impact. Christchurch. The Clinical Progress business System backups are Control Centre in Auckland continuity and emergency regularly taking place. took over all calls. preparedness work. Fault hardware One caller was subjected to has been installed. a delayed response following activation of a Business continuity plans medical alarm. A full in place for internal review found no functions and are adverse outcome to that regularly reviewed. individual. External review by PwC completed – recommendations being implemented. 9 St John A Fire Service paging The cause and duration of Review all areas and Dual frequency settings system utilised by St John the failure were unable to be situations where of first response unit failed and resources identified. paging pagers tested. nearest to a cardiac arrest systems used by St John A technological repair Deletion of personal were not activated. are provided by the NZFS discovered another identification code from paging system. Fire attended and reported unresolved issue that has computer aided dispatch the patient as deceased at since been resolved. Regularly review (CAD) system to exclude the scene; this was paging dual use of first response confirmed by ambulance. systems by clinical control unit individual pagers. services. Other events # Provider Summary of Root causes Recommendations Actions taken None
Equipment-related events # Provider Summary of event Root causes Recommendations Actions taken 8 St John A technology failure of network switches resulted in in the loss of the majority of critical operations applications and related functionality within the Clinical Control Centre in Christchurch. The Clinical Control Centre in Auckland took over all calls. One caller was subjected to a delayed response following activation of a medical alarm. A full internal review found no adverse outcome to that individual. The fault occurred in a cluster of outdated network switches. Complete Infrastructure as a Service (IaaS) project will remove all vulnerable equipment and provide a highly computing environment. Progress business continuity and emergency preparedness work. Regularly maintaining and supporting the current technology. Escalation procedures are in place to manage patient and business impact. System backups are regularly taking place. Fault tolerant hardware has been installed. Business continuity plans in place for functions and are regularly reviewed. External review by PwC completed – recommendations being implemented. 9 St John A Fire Service paging system utilised by St John failed and resources nearest to a cardiac arrest were not activated. Fire attended and reported the patient as deceased at the scene; this was confirmed by ambulance. The cause and duration of the failure were unable to be identified. A technological repair discovered another unresolved issue that has since been resolved. Review all areas and situations where paging systems used by St John are provided by the NZFS paging system. Regularly review paging systems by clinical control services. Dual frequency settings of first response unit pagers tested. Deletion of personal identification code from computer aided dispatch (CAD) system to exclude dual use of first response unit individual pagers. Other events # Provider Summary of Root causes Recommendations Actions taken None