Serious code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Serious 5 1 Patient died as a result of an Patient’s allergy/adverse reaction Discussion to be taken to In progress. allergic reaction to status was not checked prior to Medication Safety Forum and medication. medication administration. agree plan of action from there. Serious 11 1 Outpatient suicide after No issues identified with care Nil. N/A discharge from inpatient provided. mental health facility. Serious 11 1 Outpatient suicide after Client was discharged from inpatient To the time period clients In progress. discharge from inpatient facility and not followed up by the discharged from inpatient facility mental health facility. key worker within the timeframe he to community mental health was told would happen. adult urban teams. Medical staff orientation did not To ensure that clients of team include requirements of the key members who are on leave are worker role. allocated to another member of the team during the period of that leave. To develop a medical staff orientation process that includes requirements of the key worker role. Serious 11 1 Client committed suicide Non-compliance with treatment Community team staff to be In progress. whilst on weekend leave planning policy. informed of this learning arising from inpatient facility. from this event review. Serious 11 1 Inpatient suicide attempt that Handover did not include all relevant To revise and review handover In progress. resulted in injury. information including risk status. process. Risk management information is To review staff workload and documented on a number of allocation processes. different forms including the clinical To review how the risk record but not in the MDT plan. management is documented. Staff shortages led to reduced supervision of junior staff. Serious 11 1 Outpatient suicide six days No findings. Family advised of outcome from In progress. after contact with service. review. Serious 6 1 Patient fall resulting in an Patient’s clinical condition To undertake a DHB-wide Implementation of injury that required surgery contributed to the fall. project to identify best practice project recommendations to repair. strategies to reduce patient under way. harm from falls.
Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Serious 5 1 Patient died as a result of an allergic reaction to medication. Patient’s allergy/adverse reaction status was not checked prior to medication administration. Discussion to be taken to Medication Safety Forum and agree plan of action from there. In progress. Serious 11 1 Outpatient suicide after discharge from inpatient mental health facility. No issues identified with care provided. Nil. N/A Serious 11 1 Outpatient suicide after discharge from inpatient mental health facility. Client was discharged from inpatient facility and not followed up by the key worker within the timeframe he was told would happen. Medical staff orientation did not include requirements of the key worker role. To the time period clients discharged from inpatient facility to community mental health adult urban teams. To ensure that clients of team members who are on leave are allocated to another member of the team during the period of that leave. To develop a medical staff orientation process that includes requirements of the key worker role. In progress. Serious 11 1 Client committed suicide whilst on weekend leave from inpatient facility. Non-compliance with treatment planning policy. Community team staff to be informed of this learning arising from this event review. In progress. Serious 11 1 Inpatient suicide attempt that resulted in injury. Handover did not include all relevant information including risk status. Risk management information is documented on a number of different forms including the clinical record but not in the MDT plan. Staff shortages led to reduced supervision of junior staff. To revise and review handover process. To review staff workload and allocation processes. To review how the risk management is documented. In progress. Serious 11 1 Outpatient suicide six days after contact with service. No findings. Family advised of outcome from review. In progress. Serious 6 1 Patient fall resulting in an injury that required surgery to repair. Patient’s clinical condition contributed to the fall. To undertake a DHB-wide project to identify best practice strategies to reduce patient harm from falls. Implementation of project recommendations under way.