Auckland Serious Event code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Serious 6 2 Inpatient fall causing Not formally reviewed. Update / expand falls prevention In progress. fractured hip. programme. Serious 6 2 Inpatient fall causing Not formally reviewed. Update / expand falls prevention In progress. fractured hip. programme. Serious 6 2 Inpatient fall causing Not formally reviewed. Update / expand falls prevention In progress. fractured hip. programme. Serious 4a 2 Transferred from emergency Delay in specialist registrar review. Escalation to consultant after one Implemented. department to ward in hour. No medical review prior to transfer. unstable state prior to Modify nurse handover. Inadequate nursing handover. specialist team review. No long-term adverse outcome. Serious 4d 2 Excessive X-ray dose during Default settings used rather than Change to dose checking Implemented. cardiac investigation. reduced dose for patient size. process. No immediate adverse effects. Use of out”. “time Sentinel 1 1 Scalp incision made on Consent form had incorrect side Improved documentation. Currently under audit. incorrect side. noted. Consistent use of marking Implemented. out” process only partially operative side. “Time used. Full implementation of out” Completed. “time check. Serious 6 2 Inpatient fall causing Not formally reviewed. Update / expand falls prevention In progress. fractured hip. programme. Sentinel 4d 1 Fatal blood loss due to No cause for disconnection found all Ensure circuit lines are visible at Patient compliance has disconnection of dialysis procedures followed appropriately. all times. limited implementation. circuit. Machines unable to detect early Advise other dialysis services of circuit leakage. risk. Serious 4b 2 Six-hour delay in surgery for Priority initially correct, but not Escalation to specialist level if Implemented. bleeding, patient’s condition revised as patient not reviewed while unable to review in an deteriorated significantly. waiting. appropriate timeframe. No long-term adverse outcome.
Auckland Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand falls prevention programme. In progress. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand falls prevention programme. In progress. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand falls prevention programme. In progress. Serious 4a 2 Transferred from emergency department to ward in unstable state prior to specialist team review. Delay in specialist registrar review. No medical review prior to transfer. Inadequate nursing handover. No long-term adverse outcome. Escalation to consultant after one hour. Modify nurse handover. Implemented. Serious 4d 2 Excessive X-ray dose during cardiac investigation. Default settings used rather than reduced dose for patient size. No immediate adverse effects. Change to dose checking process. Use of “time out”. Implemented. Sentinel 1 1 Scalp incision made on incorrect side. Consent form had incorrect side noted. “Time out” process only partially used. Improved documentation. Currently under audit. Consistent use of marking operative side. Implemented. Full implementation of “time out” check. Completed. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand falls prevention programme. In progress. Sentinel 4d 1 Fatal blood loss due to disconnection of dialysis circuit. No cause for disconnection found all procedures followed appropriately. Machines unable to detect early circuit leakage. Ensure circuit lines are visible at all times. Advise other dialysis services of risk. Patient compliance has limited implementation. Serious 4b 2 Six-hour delay in surgery for bleeding, patient’s condition deteriorated significantly. Priority initially correct, but not revised as patient not reviewed while waiting. No long-term adverse outcome. Escalation to specialist level if unable to review in an appropriate timeframe. Implemented.