Sentinel 4B 1 Cellphone failure resulted Procedures for obtaining Procedures for obtaining alternative specialist Action completed. in in obtaining alternative specialist support support to be developed. specialist support required. necessitating emergency Failure of cellphone without procedure to be alternative back options commenced by registrar available. inexperience in this procedure. Patient survived procedure but died at a later time. Serious 4D 2 Neonatal death of an Dislodgement of ETT tube not Movements of the baby’s head should be These extremely premature recognised clinically or minimised to prevent the chance of ETT recommendations baby following insertion radiologically. movement. are currently being of an endotracheal tube implemented. The prematurity of the baby’s That the X-rays in this case and any others of (ETT). skin caused difficulties in malpositioned ETT are maintained in a adequately securing the ETT in deidentified form to be utilised for teaching place. purposes. The difficulty of detecting this The introduction of a double check protocol for complication radiologically in ETT placement. neonates resulted in the A review of current policy with regards to the dislodgement not being noted. frequency and method of checking an ETT The baby’s admission occurred placement where there is difficulty in securing hours”. This resulted in a the ETT. “after delay of regular Radiology review of the chest X-ray until the following morning. Sentinel 4G 1 Recently discharged No causal factors identified. No recommendations. Nil mental health outpatient found dead from suicide. Sentinel 4G 1 Suicide of mental health RCA under way. Report awaited. outpatient. Sentinel 4F 1 Unexpected death of Possibility that the patient Patient to remain in ICU and monitored for four Actions completed. patient following became re-narcotised on the post-narcotic reversal. discharge from ICU who ward. had received reversal of Potential benefit from longer narcotic. period of observation in ICU.
Sentinel 4B 1 Cellphone failure resulted in in obtaining specialist support necessitating emergency procedure to be commenced by registrar inexperience in this procedure. Patient survived procedure but died at a later time. Procedures for obtaining alternative specialist support required. Failure of cellphone without alternative back options available. Procedures for obtaining alternative specialist support to be developed. Action completed. Serious 4D 2 Neonatal death of an extremely premature baby following insertion of an endotracheal tube (ETT). Dislodgement of ETT tube not recognised clinically or radiologically. The prematurity of the baby’s skin caused difficulties in adequately securing the ETT in place. The difficulty of detecting this complication radiologically in neonates resulted in the dislodgement not being noted. The baby’s admission occurred “after hours”. This resulted in a delay of regular Radiology review of the chest X-ray until the following morning. Movements of the baby’s head should be minimised to prevent the chance of ETT movement. That the X-rays in this case and any others of malpositioned ETT are maintained in a deidentified form to be utilised for teaching purposes. The introduction of a double check protocol for ETT placement. A review of current policy with regards to the frequency and method of checking an ETT placement where there is difficulty in securing the ETT. These recommendations are currently being implemented. Sentinel 4G 1 Recently discharged mental health outpatient found dead from suicide. No causal factors identified. No recommendations. Nil Sentinel 4G 1 Suicide of mental health outpatient. RCA under way. Report awaited. Sentinel 4F 1 Unexpected death of patient following discharge from ICU who had received reversal of narcotic. Possibility that the patient became re-narcotised on the ward. Potential benefit from longer period of observation in ICU. Patient to remain in ICU and monitored for four post-narcotic reversal. Actions completed.
Serious-and-Sentinel-Events-Cases-2008_09.docx