Lakes District Health Board www.lakesdhb.govt.nz Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 6 Patient fall resulting in Falls Risk Assessment not Discussions with ward staff regarding Bi-monthly Falls Committee fractured hip and completed on admission. History Falls Risk Assessments being Meetings. surgery. indicated falls risk. completed on admission. DHB participating in National DHB has implemented a Falls Working on Falls Committee which is preparing an Prevention. DHB will implement annual plan and identifying a review national guidelines when process of falls strategies. agreed. Feedback regarding falls strategies Units implementing their own to be given to the governance groups local falls initiatives and of all services. undertaking regular falls audits. Serious 4B Anticoagulants CHADS scoring (Clinical prediction DHB will review scoring CHADS scoring is in the policy. discontinued when they tool for determining the risk of guideline as it impacts across the Nurse-led specialists are in were clinically indicated. stroke) is not routinely undertaken service. position for preoperative clinics. as part of DHB guidelines as Colorectal nurse position is not Patient suffered a stroke Surgical Services is currently bridging therapy in the yet funded. on day of procedure reviewing the preoperative care care process. requiring longer hospital documentation and this has stay and ongoing highlighted the need for a more rehabilitation. approach to management of anticoagulation. Surgical Services is developing a proposal for a colorectal nurse specialist position. Such a position will aim to provide a more comprehensive care programme for all patients and reduce the likelihood of such events in the future.
Lakes District Health Board www.lakesdhb.govt.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 6 Patient fall resulting in fractured hip and surgery. Falls Risk Assessment not completed on admission. History indicated falls risk. Discussions with ward staff regarding Falls Risk Assessments being completed on admission. DHB has implemented a Falls Committee which is preparing an annual plan and identifying a review process of falls strategies. Feedback regarding falls strategies to be given to the governance groups of all services. Bi-monthly Falls Committee Meetings. DHB participating in National Working on Falls Prevention. DHB will implement national guidelines when agreed. Units implementing their own local falls initiatives and undertaking regular falls audits. Serious 4B Anticoagulants discontinued when they were clinically indicated. Patient suffered a stroke on day of procedure requiring longer hospital stay and ongoing rehabilitation. CHADS scoring (Clinical prediction tool for determining the risk of stroke) is not routinely undertaken as part of DHB guidelines as bridging therapy in the care process. DHB will review scoring guideline as it impacts across the service. Surgical Services is currently reviewing the preoperative care documentation and this has highlighted the need for a more approach to management of anticoagulation. Surgical Services is developing a proposal for a colorectal nurse specialist position. Such a position will aim to provide a more comprehensive care programme for all patients and reduce the likelihood of such events in the future. CHADS scoring is in the policy. Nurse-led specialists are in position for preoperative clinics. Colorectal nurse position is not yet funded.