1 side prosthesis Timeout procedure did not Timeout guidelines improved to include RCA completed. inserted during elective include prosthesis couple with equipment check. Recommendations surgery resulting is staff unfamiliar with the Improve labelling and storage of prosthetics. implemented. further surgery. prosthetics the wrong side was Improve cross-skilling of staff to reduce reliance used. Replacement was not on individuals. necessary and patient has gained full range of function. Variable practice regarding the Develop and implement risk assessment tool for Referred to coroner. use of foetal monitoring during intrapartum to be carried out on admission RCA completed – labour resulting in in to the unit. recommendations recognition of foetal distress. Include risk information in handover sheets and being implemented. identify on the whiteboard. Review workforce issues staff in primary and secondary care to improve workplace culture. A structured communication tool be used to improve effective communication of patients condition between professionals. Develop formal procedure for obtaining second opinion to review CTG trace. Implement education package for the appropriate documentation and assessment of CTG tracings. Establish minimum requirements training as a with annual recertification. Develop an additional clause for the Section 88 schedule 3 which reminds LMCs of their obligations under the HPCA Act to work within scope of practice and to take regular breaks to minimise risk of fatigue. Ensure LMCs have arrangements with a backup LMC for provision of periods of planned and unplanned leaver that enable 24/7 cover. Standardise CTG monitors to reduce margin of in setting alarm parameters. Set default to the normal limits of a reassuring trace. Educate staff on the use of alarms. Prevent mute of FHR and alarms.
1 side prosthesis inserted during elective surgery resulting is further surgery. Timeout procedure did not include prosthesis couple with staff unfamiliar with the prosthetics the wrong side was used. Replacement was not necessary and patient has gained full range of function. Timeout guidelines improved to include equipment check. Improve labelling and storage of prosthetics. Improve cross-skilling of staff to reduce reliance on individuals. RCA completed. Recommendations implemented. Variable practice regarding the use of foetal monitoring during labour resulting in in recognition of foetal distress. Develop and implement risk assessment tool for intrapartum to be carried out on admission to the unit. Include risk information in handover sheets and identify on the whiteboard. Review workforce issues staff in primary and secondary care to improve workplace culture. A structured communication tool be used to improve effective communication of patients condition between professionals. Develop formal procedure for obtaining second opinion to review CTG trace. Implement education package for the appropriate documentation and assessment of CTG tracings. Establish minimum requirements training as a with annual recertification. Develop an additional clause for the Section 88 schedule 3 which reminds LMCs of their obligations under the HPCA Act to work within scope of practice and to take regular breaks to minimise risk of fatigue. Ensure LMCs have arrangements with a backup LMC for provision of periods of planned and unplanned leaver that enable 24/7 cover. Standardise CTG monitors to reduce margin of in setting alarm parameters. Set default to the normal limits of a reassuring trace. Educate staff on the use of alarms. Prevent mute of FHR and alarms. Referred to coroner. RCA completed – recommendations being implemented.
Serious-and-Sentinel-Events-Cases-2008_09.docx