Serious code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Sentinel 2, 8 1 Inpatient suicide of Patient left the ward Improve security at external doors. Action completed. mental health inpatient. unobserved. Sentinel 2, 8 1 Suicide of an inpatient Risk status not updated Mental state and risk assessment must be Recommendations whilst absent without following a change in the level of repeated as soon as a change in the level of underway leave. arousal of the patient. arousal of patient is noted. Observations undertaken but not Reinforcement of documentation requirements documented. as stated in the including “observation specialling” policy. Serious 4A 2 Patient seen in ED, In hindsight the patient would Registrar may not decline an admission Actions completed. reviewed by multiple have benefited from admission without prior consultation with their specialist services and discharged. at first presentation. Difficulty in on call. Patient represented the making initial diagnosis following day, admitted illustrated by cross referral and required surgical across multiple services. No management. consistent rule regarding involvement of specialist when decision to not admit a patient under a particular service. Sentinel 4 A, B, C 1 Patient with increasing Lack of awareness of plan of Education and care pathways required Actions underway confusion managed on care for patients with regarding acute delirium. ward with sedation and delirium. Incorporate the EWS in calls to the Clinical observation. Found in Use of early warning score tool Team Coordinator to act as a prompt to further cardiac arrest. Admitted and triggers for referral to ICU identify the deteriorating patient. to ICU. Patient died. outreach team. Continuing education on the role of the ICU Role of the intensive care outreach the team required. outreach team. Sentinel 4B 1 Suicide of a mental Lack of integration between Establishment of a multidisciplinary review All health outpatient in the psychiatric emergency services group from PES and ED to improve integration recommendations emergency department. (PES) and emergency between the two services. have been department (ED). implemented. Introduce a triage system based on the MoH ED Mental Health Triage Guidelines. Establishment of a 24-hour psychiatric ED liaison position based in ED. Introduce structures to enable increased levels of observation in ED. Review policies and procedures on the transfer of identified patients to ED.
Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 2, 8 1 Inpatient suicide of mental health inpatient. Patient left the ward unobserved. Improve security at external doors. Action completed. Sentinel 2, 8 1 Suicide of an inpatient whilst absent without leave. Risk status not updated following a change in the level of arousal of the patient. Observations undertaken but not documented. Mental state and risk assessment must be repeated as soon as a change in the level of arousal of patient is noted. Reinforcement of documentation requirements as stated in the “observation including specialling” policy. Recommendations underway Serious 4A 2 Patient seen in ED, reviewed by multiple services and discharged. Patient represented the following day, admitted and required surgical management. In hindsight the patient would have benefited from admission at first presentation. Difficulty in making initial diagnosis illustrated by cross referral across multiple services. No consistent rule regarding involvement of specialist when decision to not admit a patient under a particular service. Registrar may not decline an admission without prior consultation with their specialist on call. Actions completed. Sentinel 4 A, B, C 1 Patient with increasing confusion managed on ward with sedation and observation. Found in cardiac arrest. Admitted to ICU. Patient died. Lack of awareness of plan of care for patients with delirium. Use of early warning score tool and triggers for referral to ICU outreach team. Role of the intensive care outreach team. Education and care pathways required regarding acute delirium. Incorporate the EWS in calls to the Clinical Team Coordinator to act as a prompt to further identify the deteriorating patient. Continuing education on the role of the ICU outreach the team required. Actions underway Sentinel 4B 1 Suicide of a mental health outpatient in the emergency department. Lack of integration between psychiatric emergency services (PES) and emergency department (ED). Establishment of a multidisciplinary review group from PES and ED to improve integration between the two services. Introduce a triage system based on the MoH ED Mental Health Triage Guidelines. Establishment of a 24-hour psychiatric ED liaison position based in ED. Introduce structures to enable increased levels of observation in ED. Review policies and procedures on the transfer of identified patients to ED. All recommendations have been implemented.
Serious-and-Sentinel-Events-Cases-2008_09.docx