Serious 4b 3 Delayed treatment for high Admitted for treatment post Treatment to be given in INR. haemodialysis as INR 10.9. haemodialysis unit. Delayed assessment in emergency Increased supervision of department. treatment plans and prescriptions Developed minor complications. in emergency department. Delayed administration of plasma Staff advised to call nurse and delayed Prothrombinex specialists if too busy. administration. Serious 5 3 Medication incident. Patient prescribed 900 mgs of Accepted abbreviations No long-term effects for Amiodarone for 3D then 300 mg BD. reinforced. patient. 3D was interpreted as three days. Appropriate dosage reviewed Patient received 6 x 900 mgs over with staff and increased vigilance 48 hours. Very nauseated post reinforced. angiogram. Found that non-standard abbreviation resulting in overdose of Amiodarone. Serious 6 3 Fall unwitnessed resulting in on floor in bathroom with walker Procedures for monitoring fractured neck of femur and nearby. Assessed as having dependent patients when self surgery. fractured neck of femur and mobilising reinforced. transferred for surgery. Review of bathroom layout. Rehabilitation prolonged. Resulted in relocation. Serious 4a 3 Inadequate documentation of Patient admitted for elective Elective assessment procedures Audited. patient admitted for elective procedure. Patient deteriorated with reviewed to ensure complete procedure. fatal post-op complications. At time documentation. of deterioration and medical registrar Reinforcement of requirement for and ICU review, little information daily review and documentation was found on the admission planner, in clinical record. or any subsequent evaluation (other than for knee surgery) despite being in hospital for five days.
Serious 4b 3 Delayed treatment for high INR. Admitted for treatment post haemodialysis as INR 10.9. Delayed assessment in emergency department. Developed minor complications. Delayed administration of plasma and delayed Prothrombinex administration. Treatment to be given in haemodialysis unit. Increased supervision of treatment plans and prescriptions in emergency department. Staff advised to call nurse specialists if too busy. Serious 5 3 Medication incident. Patient prescribed 900 mgs of Amiodarone for 3D then 300 mg BD. 3D was interpreted as three days. Patient received 6 x 900 mgs over 48 hours. Very nauseated post angiogram. Found that non-standard abbreviation resulting in overdose of Amiodarone. Accepted abbreviations reinforced. Appropriate dosage reviewed with staff and increased vigilance reinforced. No long-term effects for patient. Serious 6 3 Fall unwitnessed resulting in fractured neck of femur and surgery. on floor in bathroom with walker nearby. Assessed as having fractured neck of femur and transferred for surgery. Rehabilitation prolonged. Resulted in relocation. Procedures for monitoring dependent patients when self mobilising reinforced. Review of bathroom layout. Serious 4a 3 Inadequate documentation of patient admitted for elective procedure. Patient admitted for elective procedure. Patient deteriorated with fatal post-op complications. At time of deterioration and medical registrar and ICU review, little information was found on the admission planner, or any subsequent evaluation (other than for knee surgery) despite being in hospital for five days. Elective assessment procedures reviewed to ensure complete documentation. Reinforcement of requirement for daily review and documentation in clinical record. Audited.
Serious-and-Sentinel-Events-Cases-2008_09.docx