6C SAC2 Fall whilst an inpatient. Patient admitted after stroke. Consistent documentation to be In progress. Increased confusion and history of completed by all staff when patients on Patient outcome: Alzheimer’s. On falls prevention falls/observation programmes. fractured left tibia. programme as assessed as at risk of Ongoing assessment and evaluation of falls. Patient room was away from risk factors around the patients falls nursing station. Identified as requiring risks. level 2 observation (15 minute) but not Assessment and evaluation of urinary completed at every interval. Patient elimination with toileting plan if placed on toileting plan (every two applicable implemented. hours) but also not completed at Use of Invisabeam monitoring in lieu of required times. having an environment where patients can be continuously observed by staff. 6G 2 Fall whilst an inpatient. Patient with dementia, confused and Gradual discontinuation of specialling of In progress. disorientated. Plan in place to dementia patients rather than an Patient outcome: discharge. Hip protectors in place as immediate stop to for ongoing fractured left neck of constant observation was discontinued assessment of needs of patients. femur. as per discharge plan. Patient mobilising with frame and assistance from staff. Wairarapa 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 6 N/C Inpatient fall sustaining a Patient was documented as falls No recommendations which would have Closed. # ulna. risk and precautions identified. prevented this incident as process had been On one-to-one observations in followed however it was reviewed as part of place. the Falls Management Group. Serious 6 N/C Inpatient fall sustaining a Patient stated he was using No recommendations which would have Closed. #NOF. elbow crutches incorrectly, did prevented this incident as process had been not realise until the crutch followed however it was reviewed as part of slipped. the Falls Management Group.
6C SAC2 Fall whilst an inpatient. Patient outcome: fractured left tibia. Patient admitted after stroke. Increased confusion and history of Alzheimer’s. On falls prevention programme as assessed as at risk of falls. Patient room was away from nursing station. Identified as requiring level 2 observation (15 minute) but not completed at every interval. Patient placed on toileting plan (every two hours) but also not completed at required times. Consistent documentation to be completed by all staff when patients on falls/observation programmes. Ongoing assessment and evaluation of risk factors around the patients falls risks. Assessment and evaluation of urinary elimination with toileting plan if applicable implemented. Use of Invisabeam monitoring in lieu of having an environment where patients can be continuously observed by staff. In progress. 6G 2 Fall whilst an inpatient. Patient outcome: fractured left neck of femur. Patient with dementia, confused and disorientated. Plan in place to discharge. Hip protectors in place as constant observation was discontinued as per discharge plan. Patient mobilising with frame and assistance from staff. Gradual discontinuation of specialling of dementia patients rather than an immediate stop to for ongoing assessment of needs of patients. In progress. Wairarapa 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 6 N/C Inpatient fall sustaining a # ulna. Patient was documented as falls risk and precautions identified. On one-to-one observations in place. No recommendations which would have prevented this incident as process had been followed however it was reviewed as part of the Falls Management Group. Closed. Serious 6 N/C Inpatient fall sustaining a #NOF. Patient stated he was using elbow crutches incorrectly, did not realise until the crutch slipped. No recommendations which would have prevented this incident as process had been followed however it was reviewed as part of the Falls Management Group. Closed.
Serious-and-Sentinel-Events-Cases-2008_09.docx