Emergency ambulance service reportable events For the quarter ending June 2015 (April to June 2015) About this document This document summarises all emergency ambulance service reportable events where the investigation was completed this quarter. Patient and other identifiable information have been removed to preserve patient confidentiality. Encouraging a culture of safety Emergency ambulance providers encourage their staff to report and log these events. Lessons are learnt and actions are implemented to prevent the event occurring again. The reports contribute to a culture of safety, transparency and continuous improvement. For more information More information about reportable events can be found by visiting the . For more information about specific events contact the service provider directly their – contacts details can be found on the and websites. Reportable events for this period 9 reportable event investigations were closed this quarter. 23 reportable event investigations remain open as at the end of the quarter. Clinical management events # Provider Summary of Root causes Recommendations Actions taken 1 St John An ambulance crew called A failure by the ambulance Formal debrief with staff. Formal debrief with for backup for an unwell crew to recognise a Staff to attend relevant Provided feedback to woman, but failed to cardiac rhythm. simulation-suite training. defibrillator supplier. recognise she had a It was also not recognised Staff to be supported by a cardiac rhythm. by the advisory mode clinical coach. (internal software) of the The paramedic backup defibrillator. Provide feedback to identified it and successfully defibrillator’s supplier treated it. regarding recognition capabilities. 2 St John A registered nurse from the Failure to comply with A bulletin to be issued to all Bulletin issued. Clinical Hub performed a requirements defined by the Clinical Control Centres Nurse no longer works clinical telephone Clinical Hub triage tool. stating that in all cases of within Clinical Hub. assessment and provided severe pain, an ‘orange’ Formal notification sent to incorrect advice. determinant (urgent / New Zealand Nursing potentially serious, but not See St John website () for
Emergency ambulance service reportable events For the quarter ending June 2015 (April to June 2015) About this document This document summarises all emergency ambulance service reportable events where the investigation was completed this quarter. Patient and other identifiable information have been removed to preserve patient confidentiality. Encouraging a culture of safety Emergency ambulance providers encourage their staff to report and log these events. Lessons are learnt and actions are implemented to prevent the event occurring again. The reports contribute to a culture of safety, transparency and continuous improvement. For more information More information about reportable events can be found by visiting the . For more information about specific events contact the service provider directly – their contacts details can be found on the and websites. Reportable events for this period 9 reportable event investigations were closed this quarter. 23 reportable event investigations remain open as at the end of the quarter. Clinical management events # Provider Summary of Root causes Recommendations Actions taken 1 St John An ambulance crew called for backup for an unwell woman, but failed to recognise she had a cardiac rhythm. The paramedic backup identified it and successfully treated it. A failure by the ambulance crew to recognise a cardiac rhythm. It was also not recognised by the advisory mode (internal software) of the defibrillator. Formal debrief with staff. Staff to attend relevant simulation-suite training. Staff to be supported by a clinical coach. Provide feedback to defibrillator’s supplier regarding recognition capabilities. Formal debrief with Provided feedback to defibrillator supplier. 2 St John A registered nurse from the Clinical Hub performed a clinical telephone assessment and provided incorrect advice. See St John website () for Failure to comply with requirements defined by the Clinical Hub triage tool. A bulletin to be issued to all Clinical Control Centres stating that in all cases of severe pain, an ‘orange’ determinant (urgent / potentially serious, but not Bulletin issued. Nurse no longer works within Clinical Hub. Formal notification sent to New Zealand Nursing
naso-eras-reportable-events-apr-jun-2015.docx