Not all staff were carrying a All to be trained in calming and restraint. Completed and duress alarm. ongoing. Delay in contacting the All staff are to carry a duress alarm in the Completed and responsible clinician. intensive psychiatric care unit at all times. ongoing. Emergency response delay. Compliance be audited. Processes re contacting responsible clinician Completed. to be communicated at staff meetings. New protocol and process to be introduced for Completed. emergency response and site map pre-set into ambulance location. Whanganui Serious code* SAC 1/SAC 2/ Description of Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Serious 4A 2 Eighteen-month delay in Inconsistent application of flag” alert process reiterated to all Further audit of “red “Red “red responding to an flag” process in radiology. radiologists and audited by the team leader. flag” alert process in abnormal chest X-ray, six months. No process, at the time, for All radiology reports ordered by District Health resulting in the need for communicating the results to the Board consultants are now copied to the extensive treatment. patient’s GP. patient’s GP. Delays in both reporting the Joint venture with Pacific Radiology has Xray and reviewing the X-ray. provided additional resource and minimised delays. Serious 11 2 Postmortem indicated Patient cause collapsed of and death was an amniotic died during fluid second stage embolus. of labour.
Not all staff were carrying a duress alarm. Delay in contacting the responsible clinician. Emergency response delay. All to be trained in calming and restraint. Completed and ongoing. All staff are to carry a duress alarm in the intensive psychiatric care unit at all times. Compliance be audited. Completed and ongoing. Processes re contacting responsible clinician to be communicated at staff meetings. Completed. New protocol and process to be introduced for emergency response and site map pre-set into ambulance location. Completed. Whanganui Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up Serious 4A 2 Eighteen-month delay in responding to an abnormal chest X-ray, resulting in the need for extensive treatment. Inconsistent application of “red flag” process in radiology. No process, at the time, for communicating the results to the patient’s GP. Delays in both reporting the Xray and reviewing the X-ray. “Red flag” alert process reiterated to all radiologists and audited by the team leader. All radiology reports ordered by District Health Board consultants are now copied to the patient’s GP. Joint venture with Pacific Radiology has provided additional resource and minimised delays. Further audit of “red flag” alert process in six months. Serious 11 2 Patient collapsed and died during second stage of labour. Postmortem indicated cause of death was an amniotic fluid embolus.
Serious-and-Sentinel-Events-Cases-2008_09.docx