Serious 11 2 Suspected suicide of Review in progress report in – community patient. draft. Serious 11 2 Self-harm by community The review found that some Recommendations related to use of client Action plan in patient. documentation was lacking and pathway documentation as per policy and progress. that this made it difficulty to completion of documentation of clearly understand the plan of disciplinary reviews. care while the client was an inpatient, that the timing of discharge and level of care in the community was not what the family had expected. Nelson / Marlborough 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) Serious 1 2 Wrong site surgery. A back operation was done at Orthopaedic surgeons should agree on a Guidelines agreed. the level requiring a second guideline of using the old intensifier. SMOs reminded. operation. SMOs should be reminded that concerns Fusion L4/L5 instead of L5/S1. about equipment quality and availability need Contributing to this error was to be formally documented to district poor image quality. Patient managers. recovered well after a second procedure. Serious 4c 2 A patient had a Patient was given morphine in The policy on transferring patients should be Policy completed. respiratory arrest while ED and transferred to theatre completed. Policy developed. waiting for a procedure in where has was left alone in the A policy should be developed to the care theatre. anaesthetic room. When the of patients while in operating theatre suites. nurse entered the room, she This should include the principle that a patient noticed the patient deeply is never to be left alone. cyanosed. He was resuscitated and recovered well.
Serious 11 2 Suspected suicide of community patient. Review in progress – report in draft. Serious 11 2 Self-harm by community patient. The review found that some documentation was lacking and that this made it difficulty to clearly understand the plan of care while the client was an inpatient, that the timing of discharge and level of care in the community was not what the family had expected. Recommendations related to use of client pathway documentation as per policy and completion of documentation of disciplinary reviews. Action plan in progress. Nelson / Marlborough 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 Serious 1 2 Wrong site surgery. A back operation was done at the level requiring a second operation. Fusion L4/L5 instead of L5/S1. Contributing to this error was poor image quality. Patient recovered well after a second procedure. Orthopaedic surgeons should agree on a guideline of using the old intensifier. SMOs should be reminded that concerns about equipment quality and availability need to be formally documented to district managers. Guidelines agreed. SMOs reminded. Serious 4c 2 A patient had a respiratory arrest while waiting for a procedure in theatre. Patient was given morphine in ED and transferred to theatre where has was left alone in the anaesthetic room. When the nurse entered the room, she noticed the patient deeply cyanosed. He was resuscitated and recovered well. The policy on transferring patients should be completed. A policy should be developed to the care of patients while in operating theatre suites. This should include the principle that a patient is never to be left alone. Policy completed. Policy developed.
Serious-and-Sentinel-Events-Cases-2008_09.docx