Hutt Valley Serious Event code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Sentinel 4B 1 Patient with disability An internal and external review Most of the recommendations relate to Progress against the underwent abdominal undertaken. A wide ranging set improvements required in the assessment action plan is feeding tube insertion of recommendations were made and planning of care for people with monitored quarterly: procedure. Bowel as a result of the review disabilities, especially when in the acute care eg, May 2009, August perforated during the process. setting. 2009, November surgical insertion 2009, and February NB: Patient died in May 2008 so A comprehensive action plan based on the procedure. This 2010. this should have been reported recommendations of the external reviewers complication not in the previous serious/sentinel is in place and under regular review. diagnosed immediately, report to 30 June 2008. The summary report and actions were and patient subsequently shared with the Health and Disability died from infection. Commissioners, the Ministry of Health, the media and all District Health Boards. Sentinel 4B 1 Patient with disability There were delays in the patient Improvements required in the way All recommendations died following being assessed by a surgical assessment and care planning meets the are currently being complications registrar in the emergency needs of disabled persons in the acute worked on with abdominal surgery. department, inadequate nursing setting (linked to the above case). progress reported care and failure to take account quarterly as part of Improvements in the electronic record of the patient’s disability needs. the case listed above. functions in the emergency department. The health and Disability Work also continues Review of the surgical registrar role in Commissioner found Hutt Valley on meeting the target relation to time taken to see patients in the DHB in breach of Right 4 of the for waiting times in emergency department. Code of Health and Disability the emergency Review of training provided to nursing staff Services Consumers Rights, department. for male catheterisation. stating that the patient did not A project to manage Ensure emergency department records receive an appropriate standard the flow of acute accompany patient’s admitted to inpatient of care. patients who require wards. NB: The patient died in March surgery has been Review of the informed consent policy 2008 so this should have been completed, achieving regarding patients not competent to give reported in the previous improved informed consent. serious/sentinel report to coordination and 30/06/08. decreased waiting times for such patients.
Hutt Valley Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 4B 1 Patient with disability underwent abdominal feeding tube insertion procedure. Bowel perforated during the surgical insertion procedure. This complication not diagnosed immediately, and patient subsequently died from infection. An internal and external review undertaken. A wide ranging set of recommendations were made as a result of the review process. NB: Patient died in May 2008 so this should have been reported in the previous serious/sentinel report to 30 June 2008. Most of the recommendations relate to improvements required in the assessment and planning of care for people with disabilities, especially when in the acute care setting. A comprehensive action plan based on the recommendations of the external reviewers is in place and under regular review. The summary report and actions were shared with the Health and Disability Commissioners, the Ministry of Health, the media and all District Health Boards. Progress against the action plan is monitored quarterly: eg, May 2009, August 2009, November 2009, and February 2010. Sentinel 4B 1 Patient with disability died following complications abdominal surgery. There were delays in the patient being assessed by a surgical registrar in the emergency department, inadequate nursing care and failure to take account of the patient’s disability needs. The health and Disability Commissioner found Hutt Valley DHB in breach of Right 4 of the Code of Health and Disability Services Consumers Rights, stating that the patient did not receive an appropriate standard of care. NB: The patient died in March 2008 so this should have been reported in the previous serious/sentinel report to 30/06/08. Improvements required in the way assessment and care planning meets the needs of disabled persons in the acute setting (linked to the above case). Improvements in the electronic record functions in the emergency department. Review of the surgical registrar role in relation to time taken to see patients in the emergency department. Review of training provided to nursing staff for male catheterisation. Ensure emergency department records accompany patient’s admitted to inpatient wards. Review of the informed consent policy regarding patients not competent to give informed consent. All recommendations are currently being worked on with progress reported quarterly as part of the case listed above. Work also continues on meeting the target for waiting times in the emergency department. A project to manage the flow of acute patients who require surgery has been completed, achieving improved coordination and decreased waiting times for such patients.
Serious-and-Sentinel-Events-Cases-2008_09.docx