Serious 6 2 Patient fall, Patient was a known high falls risk and had the call bell All patients that are assessed to Completed. fractured arm. within reach, and bedsides insitu at night, to reduce the be high falls risk should have a likelihood of mobilising independently. falls alarm in situ. Patient had rung the bell for assistance but got out of bed Ensure all patients that are unaided and was witnessed slipping to the floor as assessed to be high falls risk are nursing staff got to room. toileted before settling at night. X-ray examination confirmed a fractured Colles that Falls prevention programme In progress. required surgical intervention. now in pilot phase. Serious 6 2 Patient fall, Patient was conservatively treated for a fractured left Admitting house surgeons made Completed. fractured left proximal femur, recently transferred to the rehabilitation aware of the importance of proximal femur. ward. requesting nurse or physiotherapist assistance for While admission process was taking place including a mobility assessments. revision of the patient’s mobility assessment, patient lost balance and fell while transferring chair to bed. Falls prevention programme In progress. now in pilot phase. X-ray confirmed another fracture of the left proximal femur and surgery (revision of the patients left total hip replacement) was then required. Southland Serious Event code* SAC 1/SAC 2/ Description of Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Sentinel 1 1 Wrong site surgery. Patient required readmission RCA in progress. Awaiting final and extended stay. report. No long-term consequences. Serious 4b 2 Baby delivered in Hospital emergency kit to accompany patients Patient presented Complete. to helicopter enroute during to transit, equipment must be accessible hospital in pre term labour secondary maternity at all times. (scheduled for caesarean
Serious 6 2 Patient fall, fractured arm. Patient was a known high falls risk and had the call bell within reach, and bedsides insitu at night, to reduce the likelihood of mobilising independently. Patient had rung the bell for assistance but got out of bed unaided and was witnessed slipping to the floor as nursing staff got to room. X-ray examination confirmed a fractured Colles that required surgical intervention. All patients that are assessed to be high falls risk should have a falls alarm in situ. Ensure all patients that are assessed to be high falls risk are toileted before settling at night. Completed. Falls prevention programme now in pilot phase. In progress. Serious 6 2 Patient fall, fractured left proximal femur. Patient was conservatively treated for a fractured left proximal femur, recently transferred to the rehabilitation ward. While admission process was taking place including a revision of the patient’s mobility assessment, patient lost balance and fell while transferring chair to bed. X-ray confirmed another fracture of the left proximal femur and surgery (revision of the patients left total hip replacement) was then required. Admitting house surgeons made aware of the importance of requesting nurse or physiotherapist assistance for mobility assessments. Completed. Falls prevention programme now in pilot phase. In progress. Southland Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up Sentinel 1 1 Wrong site surgery. Patient required readmission and extended stay. No long-term consequences. RCA in progress. Awaiting final report. Serious 4b 2 Baby delivered in helicopter enroute to secondary maternity Patient presented to hospital in pre term labour (scheduled for caesarean Hospital emergency kit to accompany patients during transit, equipment must be accessible at all times. Complete.
Serious-and-Sentinel-Events-Cases-2008_09.docx