Serious 4B 2 Child received overdose of Misread guideline, using adult Highlight paediatric section of All implemented or fluids. instead of paediatric section to guideline. underway. calculate fluid. Improve protocol access. Limited review of treatment on implement smart pump transfer from emergency department technology. to paediatric ward. Develop and precalculated weight-based infusion guidelines. Develop transfer protocols for paediatric patients. Revise paediatric fluid guidelines. Sentinel 4D 1 Cardiac arrest during No clear risk factors. Full complement of theatre staff None required. laparoscopic surgery. even during low risk procedures. Likely rare complication of gas entering circulation. All treatment appropriate. Sentinel 3 1 Swab retained post surgery. under review. Pending. Pending. Delayed recognition even though visible on x-rays. Waitemata Serious Event code* SAC 1/SAC 2/ Description of trial Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified)
Serious 4B 2 Child received overdose of fluids. Misread guideline, using adult instead of paediatric section to calculate fluid. Limited review of treatment on transfer from emergency department to paediatric ward. Highlight paediatric section of guideline. Improve protocol access. implement smart pump technology. Develop and precalculated weight-based infusion guidelines. Develop transfer protocols for paediatric patients. Revise paediatric fluid guidelines. All implemented or underway. Sentinel 4D 1 Cardiac arrest during laparoscopic surgery. No clear risk factors. Likely rare complication of gas entering circulation. All treatment appropriate. Full complement of theatre staff even during low risk procedures. None required. Sentinel 3 1 Swab retained post surgery. Delayed recognition even though visible on x-rays. under review. Pending. Pending. Waitemata Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up trial
Serious-and-Sentinel-Events-Cases-2008_09.docx