Serious 5 2 Due to unclear prescribing, Unclear documentation on Ambiguous doses on chart to be Ward pharmacists to check incorrect dispensing and drug medication chart. confirmed with ward pharmacist. with prescriber where administration an elderly ambiguous dose identified. Failure of pharmacy checking New standard operating patient received an 8 x system to identify error. procedures developed describing annotation policy for overdose of medication over how charts are to be annotated ward pharmacists now in prolonged period. and validated by pharmacists so place. that are clear to all and not open to interpretation. Serious 6 2 Patient fall resulting in Repeat falls risk assessment not All patients undergo risk Operational Committee set fractured humerus. carried out after patient’s condition assessment using standardised up to develop a consistent changed. tool. organisation wide evidence based approach to falls Nursing to consider introducing prevention and hourly rounds in the ward to management with a target review patients. of reducing falls by 10%. Falls prevention role to be Nurse coordinator implemented and supported in all appointed to co-ordinate ward / unit areas. implementation of falls prevention strategy across organisation. Serious 6 2 Patient fall resulting in No low bed available at the time. As above. As above. fractured hip requiring Bathroom in room unavailable so Develop contingency plan to Completed. surgery. patient required walking further to ensure low beds available over access. weekend. Lack of regular toilet rounds on Patient in isolation rooms to use Commode chairs now used ward. commode chairs. for all patients in isolation rooms. Serious 6 2 Fall resulting in fractured hip Isolation status priority resulting As above. As requiring surgery. in patient being moved to unfamiliar environment away from nursing station. Sentinel 6 1 Patient fall resulting in head Staffing shortages meant person to As above. As above. injury and subsequent death. watch patient constantly not available. Serious 6 2 Patient fall resulting in High risk patient left As As above. fractured skull and subdural unsupervised. bleed (patient recovered).
Serious 5 2 Due to unclear prescribing, incorrect dispensing and drug administration an elderly patient received an 8 x overdose of medication over prolonged period. Unclear documentation on medication chart. Failure of pharmacy checking system to identify error. Ambiguous doses on chart to be confirmed with ward pharmacist. New standard operating procedures developed describing how charts are to be annotated and validated by pharmacists so that are clear to all and not open to interpretation. Ward pharmacists to check with prescriber where ambiguous dose identified. annotation policy for ward pharmacists now in place. Serious 6 2 Patient fall resulting in fractured humerus. Repeat falls risk assessment not carried out after patient’s condition changed. All patients undergo risk assessment using standardised tool. Nursing to consider introducing hourly rounds in the ward to review patients. Falls prevention role to be implemented and supported in all ward / unit areas. Operational Committee set up to develop a consistent organisation wide evidence based approach to falls prevention and management with a target of reducing falls by 10%. Nurse coordinator appointed to co-ordinate implementation of falls prevention strategy across organisation. Serious 6 2 Patient fall resulting in fractured hip requiring surgery. No low bed available at the time. As above. As above. Bathroom in room unavailable so patient required walking further to access. Develop contingency plan to ensure low beds available over weekend. Completed. Lack of regular toilet rounds on ward. Patient in isolation rooms to use commode chairs. Commode chairs now used for all patients in isolation rooms. Serious 6 2 Fall resulting in fractured hip requiring surgery. Isolation status priority resulting in patient being moved to unfamiliar environment away from nursing station. As above. As Sentinel 6 1 Patient fall resulting in head injury and subsequent death. Staffing shortages meant person to watch patient constantly not available. As above. As above. Serious 6 2 Patient fall resulting in fractured skull and subdural bleed (patient recovered). High risk patient left unsupervised. As As above.