In the initial resuscitation Improved training in resuscitation throughout Ongoing. process, there was confusion the District Health Board, including regular regarding who was leading the simulation training for the cardiac arrest team emergency team. members. Review the composition of the cardiac arrest team. Review resuscitation trolleys to ensure they are standardised. The patient had no intravenous Protocol to be developed to ensure patients Developed. cannula to enable access for receiving intravenous analgesia are medication. cannulated before the first dose is administered. The defibrillator in the unit did Immediately not have a screen or printout upgraded. facility to enable to visualise heart rhythm. The resuscitation recording Resuscitation policy and procedures to be Under way. sheet was not used. reviewed and all to be educated on the application of same. Serious 4A 1 Child diagnosed with viral Disease process was the single Eleven recommendations made, relating to Under infection in emergency of the child’s death. reception, administration and triage processes consideration. department, discharged for emergency department and the medical home. Presented again clinic. the next morning with The review team did identify a Introduce liaison meetings and shared Ongoing. meningococcal number of clinical practice and education opportunities between the two septicaemia and died. systems issues which could be providers. improved. Review paediatric observation charts and Under way. parental advice sheets. Strengthen the available support to meet the Starlight emotional needs of family following a bereavement bereavement. packages purchased. Training for senior clinicians in the Ongoing. “open disclosure” process. Serious 8 and 2 2 Attempted suicide Contingency of plan to be developed to ensure High acuity Developed. and occupancy in mental health inpatient. occupancy remains below 85%. the unit. Introduce an acuity measurement tool. Under way.
In the initial resuscitation process, there was confusion regarding who was leading the emergency team. Improved training in resuscitation throughout the District Health Board, including regular simulation training for the cardiac arrest team members. Review the composition of the cardiac arrest team. Review resuscitation trolleys to ensure they are standardised. Ongoing. The patient had no intravenous cannula to enable access for medication. Protocol to be developed to ensure patients receiving intravenous analgesia are cannulated before the first dose is administered. Developed. The defibrillator in the unit did not have a screen or printout facility to enable to visualise heart rhythm. Immediately upgraded. The resuscitation recording sheet was not used. Resuscitation policy and procedures to be reviewed and all to be educated on the application of same. Under way. Serious 4A 1 Child diagnosed with viral infection in emergency department, discharged home. Presented again the next morning with meningococcal septicaemia and died. Disease process was the single of the child’s death. Eleven recommendations made, relating to reception, administration and triage processes for emergency department and the medical clinic. Under consideration. The review team did identify a number of clinical practice and systems issues which could be improved. Introduce liaison meetings and shared education opportunities between the two providers. Ongoing. Review paediatric observation charts and parental advice sheets. Under way. Strengthen the available support to meet the emotional needs of family following a bereavement. Starlight bereavement packages purchased. Training for senior clinicians in the “open disclosure” process. Ongoing. Serious 8 and 2 2 Attempted suicide of mental health inpatient. High acuity and occupancy in the unit. Contingency plan to be developed to ensure occupancy remains below 85%. Developed. Introduce an acuity measurement tool. Under way.