Northland 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 11 N/C Extreme weather associated Reliance on electronic systems. Re-positioning of computer Completed. with trial entry caused outage switchboard. Knowledge deficits. Discussion by executive of patient management Attention to maintenance. team. Lack of contingency plans. systems. Develop contingency plans. Business continuity plans under development. Serious 4A N/C Patient failed to progress in Relevant previous obstetric history Regional midwives to be Completed at education labour in regional hospital. might have prompted earlier reminded of best practice re session by Maternity Trial Subsequent transfer, transfer not obtained. obtaining obstetric history. Manager. emergency caesarean, baby Equipment shortage and Foetal monitoring machine to be Now four machines died. resuscitation processes to be purchased for theatre. throughout the service. addressed. Sentinel 4A N/C Patient presented to X-ray results filed without action. New alert process on radiology System for ensuring emergency department x 3 reporting system. clinicians alerted to over a six-year period. radiological abnormalities in taken on each presentation process. identified pulmonary tuberculosis, not actioned until third presentation. Sentinel 4A 2 Mammogram identified No process for handing on patients Database of patients requiring System in place December potential carcinoma, referral when clinician leaves. annual mammograms. 2008. never actioned. Diagnosis Radiology Department to Commence by January delayed until further proceed directly to biopsy if 2010. presentation. clinically indicated. To be completed by Process of handover. November 2009.
Northland 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 11 N/C Extreme weather associated with entry caused outage of patient management systems. Reliance on electronic systems. Knowledge deficits. Lack of contingency plans. Re-positioning of computer switchboard. Attention to maintenance. Develop contingency plans. Completed. Discussion by executive team. Business continuity plans under development. Serious 4A N/C Patient failed to progress in labour in regional hospital. Subsequent transfer, emergency caesarean, baby died. Relevant previous obstetric history might have prompted earlier transfer not obtained. Equipment shortage and resuscitation processes to be addressed. Regional midwives to be reminded of best practice re obtaining obstetric history. Foetal monitoring machine to be purchased for theatre. Completed at education session by Maternity Manager. Now four machines throughout the service. Sentinel 4A N/C Patient presented to emergency department x 3 over a six-year period. taken on each presentation identified pulmonary tuberculosis, not actioned until third presentation. X-ray results filed without action. New alert process on radiology reporting system. System for ensuring clinicians alerted to radiological abnormalities in process. Sentinel 4A 2 Mammogram identified potential carcinoma, referral never actioned. Diagnosis delayed until further presentation. No process for handing on patients when clinician leaves. Database of patients requiring annual mammograms. Radiology Department to proceed directly to biopsy if clinically indicated. Process of handover. System in place December 2008. Commence by January 2010. To be completed by November 2009. trial Trial
Serious-and-Sentinel-Events-Cases-2008_09.docx