Sentinel 4C 1 A patient admitted with Review found that immediate Review recommended: Action plan almost chest pain went onto medical response did not follow complete including the planned purchase and installation of develop a life threatening the advent of a life threatening replacement of the new cardiac monitoring system be cardiac rhythm. The arrhythmia because the cardiac cardiac monitors – completed patient’s cardiac monitor monitor did not alarm. The root one recommendation staff orientation be reviewed did not alarm which cause for the alarms not still in progress. all patients admitted to the service be delayed a medical activating appeared to be asked if they would like their family response. Resuscitation because the audible alarms on informed. unsuccessful. the cardiac monitor were turned off. The patient’s family were not contacted when the patient was admitted. Serious 6 NC Outpatient fell in car park Review found that severe wind Review did not make specific and sustained fracture. gusts blew the patient over and recommendations. injury resulted. Serious 6 NC Inpatient fall with fracture Review found the patient had Review recommended: Action plan complete been identified as a high falls and closed. Ongoing improved documentation of risk risk. Falls prevention strategies monitoring of falls in assessments were in place. Some place. compliance audit. documentation incomplete. Serious 6 2 Inpatient fall with fracture. Under review draft report in – Patient deceased a few development. hours later. Serious 6 2 Inpatient fall with fracture. Review found that this fall Review did not make specific Action plan complete occurred without warning; recommendations that would have prevented and closed. Ongoing relevant falls risk management this fall from occurring. monitoring of in was in place including direct place. supervision when mobilising and that this was an unfortunate event rather than an event that arose as a result of a deficiency in systems or processes of care.
Sentinel 4C 1 A patient admitted with chest pain went onto develop a life threatening cardiac rhythm. The patient’s cardiac monitor did not alarm which delayed a medical response. Resuscitation unsuccessful. Review found that immediate medical response did not follow the advent of a life threatening arrhythmia because the cardiac monitor did not alarm. The root cause for the alarms not activating appeared to be because the audible alarms on the cardiac monitor were turned off. The patient’s family were not contacted when the patient was admitted. Review recommended: the planned purchase and installation of the new cardiac monitoring system be completed staff orientation be reviewed all patients admitted to the service be asked if they would like their family informed. Action plan almost complete including replacement of cardiac monitors – one recommendation still in progress. Serious 6 NC Outpatient fell in car park and sustained fracture. Review found that severe wind gusts blew the patient over and injury resulted. Review did not make specific recommendations. Serious 6 NC Inpatient fall with fracture Review found the patient had been identified as a high falls risk. Falls prevention strategies were in place. Some documentation incomplete. Review recommended: improved documentation of risk assessments compliance audit. Action plan complete and closed. Ongoing monitoring of falls in place. Serious 6 2 Inpatient fall with fracture. Patient deceased a few hours later. Under review – draft report in development. Serious 6 2 Inpatient fall with fracture. Review found that this fall occurred without warning; relevant falls risk management was in place including direct supervision when mobilising and that this was an unfortunate event rather than an event that arose as a result of a deficiency in systems or processes of care. Review did not make specific recommendations that would have prevented this fall from occurring. Action plan complete and closed. Ongoing monitoring of in place.
Serious-and-Sentinel-Events-Cases-2008_09.docx