April 4D 2 Patient underwent chest Enlarged heart size made the Clinical review completed. All recommendations 2009 drain insertion to relieve fluid look larger than it was. communicated to Recommendations: the fluid on the chest and medical staff as part X-ray was two weeks prior That a recent x-ray is undertaken shortness of breath. As of ongoing education and no other imaging prior to the procedure and is viewed prior the chest drain was following clinical undertaken. to and during the procedure. inserted to drain the fluid, review. Exact location of drain not That advice is sought from the respiratory it pierced the patient’s obvious from documentation. physician if clinically indicated. heart. Patient and next of kin fully That the informed consent process is The patient was communicated with during and clearly documented in the clinical record. transferred to another following procedure. District Health Board for Attendance at teaching and training successful removal of sessions for medical be recorded. drain. Patient made full recovery. 4B 2 Patient admitted with Classified by ACC as a serious Recommendations: Action plan for 2008 inflammation on leg. treatment injury. service in place and Junior nurses to be upskilled in patient all recommendations Patient developed a Clinical review complete. assessment process. Visual skin being progressed. pressure sore from being assessment to be included in patient Areas of concern raised: immobile and required notes. Ability of junior nursing staff to surgery. Action plan and timeframe for completion assess skin and general to be completed. condition of complex patients on admission, and in the event of Service to develop guidelines with their health status changing. support from Pacific and Maori Health Units, and Disability Advisor for use when Skin assessment tool did not family/caregivers wish to be involved with reflect other complications. care. Contact has been made with family to acknowledge and apologise for the quality of care issues highlighted.
April 2009 4D 2 Patient underwent chest drain insertion to relieve the fluid on the chest and shortness of breath. As the chest drain was inserted to drain the fluid, it pierced the patient’s heart. The patient was transferred to another District Health Board for successful removal of drain. Patient made full recovery. Enlarged heart size made the fluid look larger than it was. X-ray was two weeks prior and no other imaging undertaken. Exact location of drain not obvious from documentation. Patient and next of kin fully communicated with during and following procedure. Clinical review completed. Recommendations: That a recent x-ray is undertaken prior to the procedure and is viewed prior to and during the procedure. That advice is sought from the respiratory physician if clinically indicated. That the informed consent process is clearly documented in the clinical record. Attendance at teaching and training sessions for medical be recorded. All recommendations communicated to medical staff as part of ongoing education following clinical review. 2008 4B 2 Patient admitted with inflammation on leg. Patient developed a pressure sore from being immobile and required surgery. Classified by ACC as a serious treatment injury. Clinical review complete. Areas of concern raised: Ability of junior nursing staff to assess skin and general condition of complex patients on admission, and in the event of their health status changing. Skin assessment tool did not reflect other complications. Contact has been made with family to acknowledge and apologise for the quality of care issues highlighted. Recommendations: Junior nurses to be upskilled in patient assessment process. Visual skin assessment to be included in patient notes. Action plan and timeframe for completion to be completed. Service to develop guidelines with support from Pacific and Maori Health Units, and Disability Advisor for use when family/caregivers wish to be involved with care. Action plan for service in place and all recommendations being progressed.
Serious-and-Sentinel-Events-Cases-2008_09.docx