Serious 6 2 Cognitively compromised High falls risk patient did not education on falls policy and Regular review of trended high falls risk patient have a care plan completed process and on identification of patients falls data by newly inadequately monitored therefore patient need for in need of close monitoring. established Falls resulting in fall and increased monitoring not Committee to support Audit of compliance to be conducted on fractured hip. identified. improvement opportunities. six-monthly basis. Tairawhiti Serious code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) 4B 1 Unexpected deterioration Cause of deterioration difficult Both surgeon and anaesthetist to be called for Coroner’s report and death following acute to determine. Multiple co deteriorating patients. pending. hernia repair operation. morbidities added to the A structured communication tool to be used to Recommendations complexity of patients improve effective communication of patients implemented. condition. Initial response condition. reassuring however further Patients admitted unexpectedly to ICU following deterioration and surgery need a thorough handover process to interventions. should happen including clear treatment plan (with target parameters, etc) written in the notes as well as all treatments and fluids properly charted. In most cases, a direct hand over by the doctor(s) to the ICU nurse should occur. Develop a range of standardised blood tests that should be taken shortly after admission in order to have some baseline indication and in some case to detect early the need for some therapeutic adjustments. Patients with co morbidities to be scheduled in the day.
Serious 6 2 Cognitively compromised high falls risk patient inadequately monitored resulting in fall and fractured hip. High falls risk patient did not have a care plan completed therefore patient need for increased monitoring not identified. education on falls policy and process and on identification of patients in need of close monitoring. Audit of compliance to be conducted on six-monthly basis. Regular review of trended falls data by newly established Falls Committee to support improvement opportunities. Tairawhiti Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up 4B 1 Unexpected deterioration and death following acute hernia repair operation. Cause of deterioration difficult to determine. Multiple co morbidities added to the complexity of patients condition. Initial response reassuring however further deterioration and to interventions. Both surgeon and anaesthetist to be called for deteriorating patients. A structured communication tool to be used to improve effective communication of patients condition. Patients admitted unexpectedly to ICU following surgery need a thorough handover process should happen including clear treatment plan (with target parameters, etc) written in the notes as well as all treatments and fluids properly charted. In most cases, a direct hand over by the doctor(s) to the ICU nurse should occur. Develop a range of standardised blood tests that should be taken shortly after admission in order to have some baseline indication and in some case to detect early the need for some therapeutic adjustments. Patients with co morbidities to be scheduled in the day. Coroner’s report pending. Recommendations implemented.
Serious-and-Sentinel-Events-Cases-2008_09.docx