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) Sentinel 1 1 Patient on heart monitor Incorrect and absent patient name extent of incorrect use of Audit completed. No ward wrongly identified leading to labels above beds. patient name labels in medical achieved 100%. of delay in reviewing patient wards. patient labels on beds Failure to check wrist band. after alert by coronary care rather than wall above bed Introduce bedside handover as Lack of bedside handover process. unit team. Emergency team being considered. part of Handover Project. Vital signs not checked when called, but resuscitation The handover Draft guidelines to ensure ward coronary care unit requested patient unsuccessful and patient communication tool is staff have clear understanding of review. died. currently being trialed on expectations when asked by three wards for shift to shift, coronary care unit to review a bedside handover and patient. documentation. This includes checking of patient identification. Draft procedure written and consultation in progress. Serious 3 2 Retained clip following Changeover of nursing staff during Introduction of Safer Surgery Surgery Checklist surgery resulting in second procedure. Checklist. project under way and procedure for removal. reviewed with nursing staff Count not completed before skin Review count policy and and surgical governance closure. procedures. group. Review and update theatre Policy and procedures documentation sheets. review completed. Theatre documentation sheets reviewed and update under way. Sentinel 4A 1 Late presentation of patient to No standardised phone advice Develop agreed process for In progress. maternity services (phoned process in Assessment and Labour managing unbooked women, when in labour) with Birthing Unit. with transparent clinical unrecognised breech. prioritisation criteria and agreed No documented process for self Inadequate phone advice. timeframes. referral antenatal bookings. Baby stillborn. Standardise the booking and Lack of agreed clinical prioritisation grading process across the process for antenatal booking Women’s Health Service. referral.
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 Sentinel 1 1 Patient on heart monitor wrongly identified leading to delay in reviewing patient after alert by coronary care unit team. Emergency team called, but resuscitation unsuccessful and patient died. Incorrect and absent patient name labels above beds. Failure to check wrist band. Lack of bedside handover process. Vital signs not checked when coronary care unit requested patient review. extent of incorrect use of patient name labels in medical wards. Introduce bedside handover as part of Handover Project. Draft guidelines to ensure ward staff have clear understanding of expectations when asked by coronary care unit to review a patient. Audit completed. No ward achieved 100%. of patient labels on beds rather than wall above bed being considered. The handover communication tool is currently being trialed on three wards for shift to shift, bedside handover and documentation. This includes checking of patient identification. Draft procedure written and consultation in progress. Serious 3 2 Retained clip following surgery resulting in second procedure for removal. Changeover of nursing staff during procedure. Count not completed before skin closure. Introduction of Safer Surgery Checklist. Review count policy and procedures. Review and update theatre documentation sheets. Surgery Checklist project under way and reviewed with nursing staff and surgical governance group. Policy and procedures review completed. Theatre documentation sheets reviewed and update under way. Sentinel 4A 1 Late presentation of patient to maternity services (phoned when in labour) with unrecognised breech. Inadequate phone advice. Baby stillborn. No standardised phone advice process in Assessment and Labour Birthing Unit. No documented process for self referral antenatal bookings. Lack of agreed clinical prioritisation process for antenatal booking referral. Develop agreed process for managing unbooked women, with transparent clinical prioritisation criteria and agreed timeframes. Standardise the booking and grading process across the Women’s Health Service. In progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx