Serious 4D 2 Patient undergoing An internal review highlighted The consent form for CT scanning now We await the contrast tomography (CT) that additional information was includes an explanation of risks. outcome of the Health scan developed swelling needed on the consent form and Disability A bell has been installed in the CT scanner and subsequent scarring signed by patients for CT scan, Commissioner to enable patients to call for assistance when the contrast and that it was difficult for review. during a scan. medium used for the patients to alert staff if they Patient has received plastic surgery for the scan infiltrated into arm needed assistance immediately. scarring on their arm, and is under ongoing tissue. The contrast was The Health and Disability review by hand and scar therapists. being delivered via a tube Commissioner is currently in the patient’s arm which reviewing our response to the became displaced at complaint lodged by the patient. some stage during the procedure. Serious 4D 2 Patient had tube inserted Tube placement tip confirmed by IV policy states: No further action to assist with feeding into x-ray as being just within correct required. a) that the tip position should always be the bloodstream. Four placement. verified by a radiographer prior to use in days insertion the Chest x-ray taken four days later a clinical areas patient experienced pain to check placement due to b) that nursing staff should undertake and shortness of breath. patient complaint of pain. checking procedures to ensure Chest X-ray showed tube Patient transferred to ICU as placement is correct had perforated into chest they developed respiratory c) if in doubt, a chest X-ray should be causing infection. complications. collections performed prior to continuing or drained via a chest drain, and recommencing fluid infusion. patient made a good recovery. Serious 6 2 Inpatient fall resulting in Patient had been assessed for Patient’s falls risk assessment upgraded broken wrist. falls risk on admission, and had from moderate to high. been graded as at moderate risk Patient placed in close observation cubicle, and appropriate precautions for and medical and nursing care plan that level of risk were documented. implemented. Serious 6 2 Inpatient fall resulting in Patient assessed on admission No recommendations. fractured hip, requiring and not considered to be at risk surgery. of falling as normally independent. The patient had been undergoing preparation for surgery , and this may have contributed to the fall.
Serious 4D 2 Patient undergoing contrast tomography (CT) scan developed swelling and subsequent scarring when the contrast medium used for the scan infiltrated into arm tissue. The contrast was being delivered via a tube in the patient’s arm which became displaced at some stage during the procedure. An internal review highlighted that additional information was needed on the consent form signed by patients for CT scan, and that it was difficult for patients to alert staff if they needed assistance immediately. The Health and Disability Commissioner is currently reviewing our response to the complaint lodged by the patient. The consent form for CT scanning now includes an explanation of risks. A bell has been installed in the CT scanner to enable patients to call for assistance during a scan. Patient has received plastic surgery for the scarring on their arm, and is under ongoing review by hand and scar therapists. We await the outcome of the Health and Disability Commissioner review. Serious 4D 2 Patient had tube inserted to assist with feeding into the bloodstream. Four days insertion the patient experienced pain and shortness of breath. Chest X-ray showed tube had perforated into chest causing infection. Tube placement tip confirmed by x-ray as being just within correct placement. Chest x-ray taken four days later to check placement due to patient complaint of pain. Patient transferred to ICU as they developed respiratory complications. collections drained via a chest drain, and patient made a good recovery. IV policy states: a) that the tip position should always be verified by a radiographer prior to use in a clinical areas b) that nursing staff should undertake checking procedures to ensure placement is correct c) if in doubt, a chest X-ray should be performed prior to continuing or recommencing fluid infusion. No further action required. Serious 6 2 Inpatient fall resulting in broken wrist. Patient had been assessed for falls risk on admission, and had been graded as at moderate risk and appropriate precautions for that level of risk were implemented. Patient’s falls risk assessment upgraded from moderate to high. Patient placed in close observation cubicle, and medical and nursing care plan documented. Serious 6 2 Inpatient fall resulting in fractured hip, requiring surgery. Patient assessed on admission and not considered to be at risk of falling as normally independent. The patient had been undergoing preparation for surgery , and this may have contributed to the fall. No recommendations.
Serious-and-Sentinel-Events-Cases-2008_09.docx