Sentinel 4b 1 Fatal multi-organ failure Patient did not declare recent Document all verbal checks of Implemented. triggered by bleeding from medical history. patient history. dental extraction. History of No recheck of severity of clotting Revised surgical technique for Implemented. severe liver disease and abnormality. patients with mild clotting blood product refusal not abnormalities. known to dental staff Health questionnaires do not ask Revise health questionnaire. In progress. about treatments unacceptable to patient. Serious 4a 2 Missed lower leg fractures in Secondary trauma examination Feedback to medical staff. Completed. patient with multiple injuries. incomplete due to severity of other injuries. Serious 4a 2 x-ray report identifying Current manual system is unable to New radiology ordering, reporting $1 million software system incidental lung cancer not ensure that appropriate clinical and sign-off process. currently being reviewed by treating signoff occurs. implemented. clinicians. Previous similar Sentinel 4a 1 Undiagnosed leaking thoracic Triage 3 category appropriate. Reduce incidence of high ED National rule” “six-hour aorta leading to death in occupancy by improving patient established. Hospital and emergency department emergency department. flow to inpatient beds. full patient in low acuity room with Expansion of inpatient bed – non-ED nurse. capacity in progress. Delay in medical assessment due to high volume of cases. Preventability uncertain, but earlier assessment may have helped. Serious 4b 2 Treatment delay leading to Currently review. Currently under review. eye injury. Serious 4b 2 Delay in spinal surgery Currently under review. Currently under review. leading to reduced mobility. Serious 4a 2 Delay in identifying stone in Currently under review. Currently review. double urinary tract requiring repeat surgery. Counties Manukau
Sentinel 4b 1 Fatal multi-organ failure triggered by bleeding from dental extraction. History of severe liver disease and blood product refusal not known to dental staff Patient did not declare recent medical history. Document all verbal checks of patient history. Implemented. No recheck of severity of clotting abnormality. Revised surgical technique for patients with mild clotting abnormalities. Implemented. Health questionnaires do not ask about treatments unacceptable to patient. Revise health questionnaire. In progress. Serious 4a 2 Missed lower leg fractures in patient with multiple injuries. Secondary trauma examination incomplete due to severity of other injuries. Feedback to medical staff. Completed. Serious 4a 2 x-ray report identifying incidental lung cancer not reviewed by treating clinicians. Current manual system is unable to ensure that appropriate clinical signoff occurs. Previous similar New radiology ordering, reporting and sign-off process. $1 million software system currently being implemented. Sentinel 4a 1 Undiagnosed leaking thoracic aorta leading to death in emergency department. Triage 3 category appropriate. Hospital and emergency department full – patient in low acuity room with non-ED nurse. Delay in medical assessment due to high volume of cases. Preventability uncertain, but earlier assessment may have helped. Reduce incidence of high ED occupancy by improving patient flow to inpatient beds. National “six-hour rule” established. Expansion of inpatient bed capacity in progress. Serious 4b 2 Treatment delay leading to eye injury. Currently review. Currently under review. Serious 4b 2 Delay in spinal surgery leading to reduced mobility. Currently under review. Currently under review. Serious 4a 2 Delay in identifying stone in double urinary tract requiring repeat surgery. Currently under review. Currently review. Counties Manukau