Serious 4b 2 Bleeding from lung unable to Room not appropriately prepared for range of equipment with Implemented. be suctioned due to complexity of patient. improved labelling. inadequate equipment. Delay in resuscitation team arriving Increase nursing cover in Implemented. due to unfamiliar location. evenings. Modify resus team teaching. Implemented. Serious 5 2 Incorrect dose (20x) of 4 mmol/ml misunderstood as 4 mmol Labelling change. In progress with concentrated sodium to per 20 ml ampoule. manufacturer. IV fluids. Patient developed High concentration not emphasised Revise IV fluid protocol. In progress. critically high sodium level. on label. unfamiliar with concentrated Staff education. saline. Serious 6 2 Fall from radiology table In stable position stable for Higher risk cases to use largest Implemented. during procedure causing 45 minutes, but then turned and fell, available table. lacerated scalp. assuming procedure had ended. More instructions to patients. Larger may have prevented fall. Death next day unrelated to this injury. Serious 6 2 Inpatient fall causing Not formally reviewed. Update / expand falls prevention In progress. fractured hip. programme. Serious 11 2 Major failure of clinical Replacement of uninterruptable Revised documentation to Completed. computer systems for four power supply damaged by power support maintenance operations. hours. Significant clinical caused sequential failure of “spike” risk. multiple systems. Inadequate knowledge of trial supply Higher level authorisation for Implemented. requirements. equipment changes. Key servers had single power Upgrade of all servers to fully Mostly completed, some supplies. separated dual power supply ongoing work. Serious 4b 2 Delay in recognising and Trial probably not preventable, but Improved communication All staff involved aware of acting on severity of intervention should have occurred between medical issues. deterioration of patient with some hours earlier. pneumonia. Delay in senior medical review. Review of medical high Review in progress. dependency services. Serious 6 2 Inpatient fall causing Not formally reviewed. Update / expand prevention In progress. fractured hip. programme.
Serious 4b 2 Bleeding from lung unable to be suctioned due to inadequate equipment. Room not appropriately prepared for complexity of patient. Delay in resuscitation team arriving due to unfamiliar location. range of equipment with improved labelling. Implemented. Increase nursing cover in evenings. Implemented. Modify resus team teaching. Implemented. Serious 5 2 Incorrect dose (20x) of concentrated sodium to IV fluids. Patient developed critically high sodium level. 4 mmol/ml misunderstood as 4 mmol per 20 ml ampoule. Labelling change. In progress with manufacturer. High concentration not emphasised on label. Revise IV fluid protocol. In progress. unfamiliar with concentrated saline. Staff education. Serious 6 2 Fall from radiology table during procedure causing lacerated scalp. In stable position stable for 45 minutes, but then turned and fell, assuming procedure had ended. Larger may have prevented fall. Death next day unrelated to this injury. Higher risk cases to use largest available table. More instructions to patients. Implemented. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand falls prevention programme. In progress. Serious 11 2 Major failure of clinical computer systems for four hours. Significant clinical risk. Replacement of uninterruptable power supply damaged by power “spike” caused sequential failure of multiple systems. Revised documentation to support maintenance operations. Completed. Inadequate knowledge of supply requirements. Higher level authorisation for equipment changes. Implemented. Key servers had single power supplies. Upgrade of all servers to fully separated dual power supply Mostly completed, some ongoing work. Serious 4b 2 Delay in recognising and acting on severity of deterioration of patient with pneumonia. probably not preventable, but intervention should have occurred some hours earlier. Improved communication between medical All staff involved aware of issues. Delay in senior medical review. Review of medical high dependency services. Review in progress. Serious 6 2 Inpatient fall causing fractured hip. Not formally reviewed. Update / expand prevention programme. In progress. Trial trial
Serious-and-Sentinel-Events-Cases-2008_09.docx