Serious 6 1 Patient fall resulting in an Patient’s clinical condition To undertake a DHB-wide Implementation of falls injury that required surgery contributed to the fall. project to identify best practice project recommendations to repair. strategies to reduce patient under way. harm from falls. Serious 4(b) 1 Patient had radiology Failure to recognise and or action a The conclusion/impression In progress. investigation that was not significant incidental finding in this section of radiology reports will followed up. case an aortic abdominal aneurysm firstly include the findings/ on an inpatient between May and abnormalities in answer to the June 2008. clinical question being asked and thereafter any other significant incidental findings should be listed. Serious 11 2 Patient injured by bed rail. Patients underlying condition Ward to complete feasibility of Completed. increased susceptibility of injury. assignment of padded bed rails to specific inpatient population. Include learnings from this event in the education schedule for the ward. Serious 6 2 Patient fall with resulting Wet floor area caused patient to slip. Non-slip lino to be replaced by Completed. injury sustained. end 2008 as part of property and infrastructure upgrade programme. Serious 6 2 Patient fall with resulting Patient fell whilst attempting to turn Discussion to occur with staff on In progress. injury sustained. television off. risks in use of televisions, and management of workloads. Patient left sitting in lazy boy for Controls to be documented for longer period than normal due to dealing with low staffing risks. nurse workload. Serious 6 2 Patient fall with resulting Incomplete risk assessment carried Ensure admissions are vetted In progress. injury sustained out and patients clinical condition for appropriateness and that a contributed to the fall. clear admission process is completed on admission. Sensor mats to be sourced. Serious 11 2 Patient hit leg on side of Review in progress. wheelchair. Required surgery to repair and ongoing plastic surgery treatment.
Serious 6 1 Patient fall resulting in an injury that required surgery to repair. Patient’s clinical condition contributed to the fall. To undertake a DHB-wide project to identify best practice strategies to reduce patient harm from falls. Implementation of falls project recommendations under way. Serious 4(b) 1 Patient had radiology investigation that was not followed up. Failure to recognise and or action a significant incidental finding in this case an aortic abdominal aneurysm on an inpatient between May and June 2008. The conclusion/impression section of radiology reports will firstly include the findings/ abnormalities in answer to the clinical question being asked and thereafter any other significant incidental findings should be listed. In progress. Serious 11 2 Patient injured by bed rail. Patients underlying condition increased susceptibility of injury. Ward to complete feasibility of assignment of padded bed rails to specific inpatient population. Include learnings from this event in the education schedule for the ward. Completed. Serious 6 2 Patient fall with resulting injury sustained. Wet floor area caused patient to slip. Non-slip lino to be replaced by end 2008 as part of property and infrastructure upgrade programme. Completed. Serious 6 2 Patient fall with resulting injury sustained. Patient fell whilst attempting to turn television off. Patient left sitting in lazy boy for longer period than normal due to nurse workload. Discussion to occur with staff on risks in use of televisions, and management of workloads. Controls to be documented for dealing with low staffing risks. In progress. Serious 6 2 Patient fall with resulting injury sustained Incomplete risk assessment carried out and patients clinical condition contributed to the fall. Ensure admissions are vetted for appropriateness and that a clear admission process is completed on admission. Sensor mats to be sourced. In progress. Serious 11 2 Patient hit leg on side of wheelchair. Required surgery to repair and ongoing plastic surgery treatment. Review in progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx