Serious 1 1 Wrong site Femoral nerve block indicated for the patient due to Fracture site must always be Completed. procedure. significant pain issues not resolving by the use of oral identified by an arrow and date analgesia, position changes and traction. by the medical team using a permanent marker. House surgeon advised by medical team to administer femoral nerve block and the patient was referred to the Administration of all medications pain team for ongoing management. must follow the hospital guidelines using the five rights. House surgeon asked the patient which leg was painful to which the patient reported the left leg (current issue was fractured distal right femur) as a stent was recently inserted in the patients left leg for treatment of peripheral vascular disease. A nerve block was then administered to the incorrect leg. Serious 4B 2 Patient burned. Patient in labour cared for by a lead maternity care Review the maternity Completed. midwife developed complications and required a protocol for use of heat packs caesarean delivery. On the way to the anaesthetic room and advise the midwife to burns to the patients’ upper thighs and stomach were adhere to these. sighted by the midwife. Education session for all The burns were identified as being caused by over midwives on the correct use of heated and prolonged use of heat packs. The burns heat packs in labour. required dressing. Serious 4B 2 Patient burned. Patient was in the delivery suite and complained of leg Update for all midwives on the Completed cramps. The lead maternity midwife applied heat packs. dangers of incorrect heat pack use and the importance of Post delivery the patient complained of painful legs. On correct positioning of women in examination patient was found to have burns on both lithotomy. legs. The burns did not require dressing.
Serious 1 1 Wrong site procedure. Femoral nerve block indicated for the patient due to significant pain issues not resolving by the use of oral analgesia, position changes and traction. House surgeon advised by medical team to administer femoral nerve block and the patient was referred to the pain team for ongoing management. House surgeon asked the patient which leg was painful to which the patient reported the left leg (current issue was fractured distal right femur) as a stent was recently inserted in the patients left leg for treatment of peripheral vascular disease. A nerve block was then administered to the incorrect leg. Fracture site must always be identified by an arrow and date by the medical team using a permanent marker. Administration of all medications must follow the hospital guidelines using the five rights. Completed. Serious 4B 2 Patient burned. Patient in labour cared for by a lead maternity care midwife developed complications and required a caesarean delivery. On the way to the anaesthetic room burns to the patients’ upper thighs and stomach were sighted by the midwife. The burns were identified as being caused by over heated and prolonged use of heat packs. The burns required dressing. Review the maternity protocol for use of heat packs and advise the midwife to adhere to these. Education session for all midwives on the correct use of heat packs in labour. Completed. Serious 4B 2 Patient burned. Patient was in the delivery suite and complained of leg cramps. The lead maternity midwife applied heat packs. Post delivery the patient complained of painful legs. On examination patient was found to have burns on both legs. The burns did not require dressing. Update for all midwives on the dangers of incorrect heat pack use and the importance of correct positioning of women in lithotomy. Completed
Serious-and-Sentinel-Events-Cases-2008_09.docx