Bay of Plenty District Health www.bopdhb.govt.nz Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 3 Four months after Investigation difficult as staff recall of Improve team culture the Subject to ongoing monitoring. – surgery, retained swab event poor. productive operating theatre and identified during X-ray. team steps have been implemented Systems in place are sufficient. in theatre. Communication within to be enhanced. Serious 4D Blood stream infection Reviewed by the infection control Issues identified will be addressed Completed. resulting from an IV team. On earlier discharge when IV with the implementation of the audit line requiring long-term cannula removed it was to be recommendations. antibiotics and red. Readmitted with severe sepsis. prolonged inpatient The findings were consistent with stay. recent IV audit. Sentinel 4C Failure to recognise Lack of a standardised process of Standardised handover process is SBARR (model for effective and act on handover between departments implemented in all clinical contexts. information transfer) deteriorating condition contributed to a loss of continuity with implemented. Consideration should be given to resulting in death. plan of care. how to ensure that it is understood Failure to repeat observations that MEWS is the explicit trigger tool following abnormalities resulted in for clinical communication and the MEWS (Modified Early Warning escalation. Score) not being adequately assessed or interpreted, causing a delay in response. Serious 1 Appendix removed Abnormal position of fallopian tube. Ongoing education for surgeons to Lessons learnt shared. subsequently found to Anatomy distorted by inflammatory include identifying and confirming be an ovary. process. anatomy where anatomy is unusual. Error not noted until pathology results received.
Bay of Plenty District Health www.bopdhb.govt.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 3 Four months after surgery, retained swab identified during X-ray. Investigation difficult as staff recall of event poor. Systems in place are sufficient. Communication within to be enhanced. Improve team culture – the productive operating theatre and team steps have been implemented in theatre. Subject to ongoing monitoring. Serious 4D Blood stream infection resulting from an IV line requiring long-term antibiotics and prolonged inpatient stay. Reviewed by the infection control team. On earlier discharge when IV cannula removed it was to be red. Readmitted with severe sepsis. The findings were consistent with recent IV audit. Issues identified will be addressed with the implementation of the audit recommendations. Completed. Sentinel 4C Failure to recognise and act on deteriorating condition resulting in death. Lack of a standardised process of handover between departments contributed to a loss of continuity with plan of care. Failure to repeat observations following abnormalities resulted in the MEWS (Modified Early Warning Score) not being adequately assessed or interpreted, causing a delay in response. Standardised handover process is implemented in all clinical contexts. Consideration should be given to how to ensure that it is understood that MEWS is the explicit trigger tool for clinical communication and escalation. SBARR (model for effective information transfer) implemented. Serious 1 Appendix removed subsequently found to be an ovary. Error not noted until pathology results received. Abnormal position of fallopian tube. Anatomy distorted by inflammatory process. Ongoing education for surgeons to include identifying and confirming anatomy where anatomy is unusual. Lessons learnt shared.