Serious 4a 2 Incorrect pathological Tumour histology incorrectly No change to current systems Not applicable. diagnosis of type of tumour reported five ago. required. leading to inappropriate more Patient suffered significant toxic treatment at the time. complications of treatment. Serious 6 2 Inpatient fall causing Patient left in care of visiting family Update / expand falls prevention In progress. fractured wrist. while staff were on break. programme. Serious 4b 2 Non-fatal cardiac arrest due Inadequate planning of surgery and Multi-disciplinary planning group Implemented. to bleeding during caesarean anaesthesia. for high-risk cases. section in high-risk patient. Technical difficulties during Specific credentialing for Proposal under review. procedure. risk surgery. Review use of arterial balloons. Process revised. Serious 4b 2 Delay in receiving follow-up Post-op clinic appointment not sent Patient co-ordinator position Nurse specialist appointed. after cancer surgery. Late due to communication failure. required. identification and treatment of tumour recurrence. Sentinel 4a 1 Failure to act on significant Rest home requested blood test Test request form to have correct Letter sent to rest home. drop in patient’s using form with incorrect details. contact details. haemoglobin. Results sent to hospital staff who Requestor responsible for Patient died next day. were on leave. followup of results. Laboratory did not contact rest Laboratory to review criteria for Issue raised with home. identification and communication community laboratory. of critical results. Sentinel 2 1 Inpatient suicide in mental Currently under review. Currently under review. Not applicable. health unit. Serious 4d 2 Severe pressure ulceration High case in ICU. Modify education regarding early Implemented. requiring surgery. risk assessment. Cardiovascular instability limited frequency of patient turns. Early signs of injury not recognised. Revise approach to turns for unstable patients. Serious 8 2 Client requiring escorted Client left as staff member entered. Review monitoring and security In progress. leave absconded from systems for clients requiring Identity of patient and leave status temporarily locked ward and leave supervision in open wards. was not known. attempted suicide. Placement in open ward was appropriate.
Serious 4a 2 Incorrect pathological diagnosis of type of tumour leading to inappropriate more toxic treatment at the time. Tumour histology incorrectly reported five ago. Patient suffered significant complications of treatment. No change to current systems required. Not applicable. Serious 6 2 Inpatient fall causing fractured wrist. Patient left in care of visiting family while staff were on break. Update / expand falls prevention programme. In progress. Serious 4b 2 Non-fatal cardiac arrest due to bleeding during caesarean section in high-risk patient. Inadequate planning of surgery and anaesthesia. Multi-disciplinary planning group for high-risk cases. Implemented. Technical difficulties during procedure. Specific credentialing for surgery. Proposal under review. Review use of arterial balloons. Process revised. Serious 4b 2 Delay in receiving follow-up after cancer surgery. Late identification and treatment of tumour recurrence. Post-op clinic appointment not sent due to communication failure. Patient co-ordinator position required. Nurse specialist appointed. Sentinel 4a 1 Failure to act on significant drop in patient’s haemoglobin. Patient died next day. Rest home requested blood test using form with incorrect details. Test request form to have correct contact details. Letter sent to rest home. Results sent to hospital staff who were on leave. Requestor responsible for followup of results. Laboratory did not contact rest home. Laboratory to review criteria for identification and communication of critical results. Issue raised with community laboratory. Sentinel 2 1 Inpatient suicide in mental health unit. Currently under review. Currently under review. Not applicable. Serious 4d 2 Severe pressure ulceration requiring surgery. High risk case in ICU. Cardiovascular instability limited frequency of patient turns. Modify education regarding early risk assessment. Implemented. Early signs of injury not recognised. Revise approach to turns for unstable patients. Serious 8 2 Client requiring escorted leave absconded from temporarily locked ward and attempted suicide. Client left as staff member entered. Identity of patient and leave status was not known. Placement in open ward was appropriate. Review monitoring and security systems for clients requiring leave supervision in open wards. In progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx