Serious 6 2 Patient fall resulting in Patient’s condition changed As above. As above. – fractured pelvis. became confused and unstable on feet. No falls risk assessment completed. Serious 6 2 Patient fall resulting in Review of new bathroom layout As plus: As above plus: fractured hip requiring revealed issues, including placement Comprehensive risk assessment Comprehensive risk surgery. of grab rails, lighting and floor undertaken by Occupational assessment completed and surface. Health and Safety and sealant to sealant removed. Investigation of this fall also be removed. Working group set up to highlighted that flooring in new Review process for consider development of a building was exceptionally slippery. communicating with Cleaning specification for new Cleaning services inappropriately Services re appropriate bathrooms and flooring applied six layers of sealant to the treatment for new flooring. based upon slip-resistance floors in new building making them criteria and to establish Implement control measures to slippery. process for communicating reduce and manage spillages. with cleaning staff re Inadequate communication with Investigate cleaning ‘dry’ appropriate treatment to cleaning services re management of methods to avoid wet floors. clean floors. new floor surfaces. Review process of floor specification and selection in new buildings. Serious 11 2 Patient injured when Soft curtains between cubicles. Identify safe area for procedure barrier (bar) placed anaesthetist inject to be performed with hard between beds. High traffic area. anaesthetic into patient’s eye, between cubicles. Monitoring continues. Ward beds leave little room for staff was bumped by someone in in narrow cubicles. the adjacent cubicle. Procedure delayed, but later completed with no lasting harm to the patient. Serious 11 2 Theatre table extension gave lack of knowledge regarding Bed to be assessed by Bed assessed and way resulting in neck injury to fitting the extension and no engineering and appropriate modifications completed by patient. Patient readmitted identifying marks to match the catch modifications made to ensure engineering. for MRI and investigation of and pipe. safety of attachment. Discussed in theatre ongoing neck problems. Extension not checked before Future beds to have suitable xray meeting. Safer surgery use and no safety mechanism to attachments. checklist project under way. ensure the extension will not detach during use.
Serious 6 2 Patient fall resulting in fractured pelvis. Patient’s condition changed – became confused and unstable on feet. No falls risk assessment completed. As above. As above. Serious 6 2 Patient fall resulting in fractured hip requiring surgery. Review of new bathroom layout revealed issues, including placement of grab rails, lighting and floor surface. Investigation of this fall also highlighted that flooring in new building was exceptionally slippery. Cleaning services inappropriately applied six layers of sealant to the floors in new building making them slippery. Inadequate communication with cleaning services re management of new floor surfaces. As plus: Comprehensive risk assessment undertaken by Occupational Health and Safety and sealant to be removed. Review process for communicating with Cleaning Services re appropriate treatment for new flooring. Implement control measures to reduce and manage spillages. Investigate ‘dry’ cleaning methods to avoid wet floors. Review process of floor specification and selection in new buildings. As above plus: Comprehensive risk assessment completed and sealant removed. Working group set up to consider development of a specification for new bathrooms and flooring based upon slip-resistance criteria and to establish process for communicating with cleaning staff re appropriate treatment to clean floors. Serious 11 2 Patient injured when anaesthetist inject anaesthetic into patient’s eye, was bumped by someone in the adjacent cubicle. Procedure delayed, but later completed with no lasting harm to the patient. Soft curtains between cubicles. High traffic area. Ward beds leave little room for staff in narrow cubicles. Identify safe area for procedure to be performed with hard between cubicles. barrier (bar) placed between beds. Monitoring continues. Serious 11 2 Theatre table extension gave way resulting in neck injury to patient. Patient readmitted for MRI and investigation of ongoing neck problems. lack of knowledge regarding fitting the extension and no identifying marks to match the catch and pipe. Extension not checked before use and no safety mechanism to ensure the extension will not detach during use. Bed to be assessed by engineering and appropriate modifications made to ensure safety of attachment. Future beds to have suitable xray attachments. Bed assessed and modifications completed by engineering. Discussed in theatre meeting. Safer surgery checklist project under way.
Serious-and-Sentinel-Events-Cases-2008_09.docx