Serious 4g 2 Patient’s discharge was Review in progress. unsafe from private hospital. Care was being provided under contracted service. Serious 4f 2 Unwell patient transferred to Incomplete patient assessment clinical records to In progress. another hospital without carried out by team involved. determine compliance with nurse escort. transfer requirements. Serious 11 2 Child patient sustained an Item had wooden frame on end that Hazards clearly identified in Completed. injury while attending clinic. fell on child. area. Children assist with clearing items Children supervised moving or as part of therapy. carrying objects. Serious 4f 2 Deteriorating patient Review in progress. transferred from ICU to ward and then had to be readmitted to ICU. Serious 4d 2 Patient injury occurred Review completed and was Nil. Family advised of findings during nasotracheal unfortunate episode. Staff involved and ongoing support intubation procedure. were very experienced. provided to them. Serious 4b 2 Deteriorating patient. Review in progress. Medical team did not respond in a timely manner to review patient. Serious 4b 2 Patient diagnosed with Review in progress. invasive cancer on follow-up appointment. Serious 4f 2 Patient transferred to Staff did not recognise deteriorating Escalation process in place. In progress DHB wide – another hospital in very patient condition. Communication project in place for Include learnings from this event unstable condition. between hospitals was not thorough deteriorating patient. in staff education forums. or effective.
Serious 4g 2 Patient’s discharge was unsafe from private hospital. Care was being provided under contracted service. Review in progress. Serious 4f 2 Unwell patient transferred to another hospital without nurse escort. Incomplete patient assessment carried out by team involved. clinical records to determine compliance with transfer requirements. In progress. Serious 11 2 Child patient sustained an injury while attending clinic. Item had wooden frame on end that fell on child. Children assist with clearing items as part of therapy. Hazards clearly identified in area. Children supervised moving or carrying objects. Completed. Serious 4f 2 Deteriorating patient transferred from ICU to ward and then had to be readmitted to ICU. Review in progress. Serious 4d 2 Patient injury occurred during nasotracheal intubation procedure. Review completed and was unfortunate episode. Staff involved were very experienced. Nil. Family advised of findings and ongoing support provided to them. Serious 4b 2 Deteriorating patient. Medical team did not respond in a timely manner to review patient. Review in progress. Serious 4b 2 Patient diagnosed with invasive cancer on follow-up appointment. Review in progress. Serious 4f 2 Patient transferred to another hospital in very unstable condition. Staff did not recognise deteriorating patient condition. Communication between hospitals was not thorough or effective. Escalation process in place. Include learnings from this event in staff education forums. In progress – DHB wide project in place for deteriorating patient.