Serious 11 Patient died at home Review found communication Review recommended: Action plan almost 24 hours after being between service providers was complete one – improved internal and external discharged. fragmented and that the practice recommendation in interagency communication of planning discharge on Fridays progress. amended discharge planning created risk in this specific relevant. situation due to significant change in service provision process required for weekend cover. Serious 5 Medication error resulting The review found of primary Review recommended: Action plan is in in cardiac arrest. Patient importance was the practice of progress: urgent review of the storage of and resuscitated, required storing a potentially dangerous access to the medication across all quality admission to ICU, medication next to a commonly clinical areas improvement returned to ward and used relatively innocuous convened to review of medication cupboards in the later discharged. medication. Omission of double implement actions service checking, bedside checking and from the review separation and clear identification of human factors contributed. findings circulated dangerous medications Review also noted an issue with to other DHBs, look alike medications the – review of hospital wide intravenous (IV) Pharmac and QIC plastic ampoules looked similar certification processes and education to Safe Use of and the differences in visual ensure risks of the medication are Medicines Group presentation are not a significant highlighted to all clinical staff. newsletter to all barrier to misidentifying the clinical staff. medication being selected. Serious 5 Medication resulting Review found that this error Review recommended: Action plan almost in reaction and tinnitus occurred because a complete one ‘medication – requirement for label ‘medication later reported. added’ label was not attached to recommendation in fastened securely to syringe. Use of the syringe containing the progress. second medication added label required antibiotic. There was also a when titrating (rate/dose adjustment) delay between the preparation inform family when administering and administration. medications staff education. Serious 4a Missed diagnosis Review found that clinical Review recommended: Action plan complete – permanent harm examination findings were not and closed. apology to the patient and provision of resulted. compatible with the diagnosis, the report and that it was likely that a risk of error continue to be emphasised in change had occurred in the training to staff. clinical presentation subsequently.
Serious 11 Patient died at home 24 hours after being discharged. Review found communication between service providers was fragmented and that the practice of planning discharge on Fridays created risk in this specific situation due to significant change in service provision process required for weekend cover. Review recommended: improved internal and external interagency communication amended discharge planning relevant. Action plan almost complete – one recommendation in progress. Serious 5 Medication error resulting in cardiac arrest. Patient resuscitated, required admission to ICU, returned to ward and later discharged. The review found of primary importance was the practice of storing a potentially dangerous medication next to a commonly used relatively innocuous medication. Omission of double checking, bedside checking and human factors contributed. Review also noted an issue with look alike medications – the plastic ampoules looked similar and the differences in visual presentation are not a significant barrier to misidentifying the medication being selected. Review recommended: urgent review of the storage of and access to the medication across all clinical areas review of medication cupboards in the service separation and clear identification of dangerous medications review of hospital wide intravenous (IV) certification processes and education to ensure risks of the medication are highlighted to all clinical staff. Action plan is in progress: quality improvement convened to implement actions from the review findings circulated to other DHBs, Pharmac and QIC Safe Use of Medicines Group newsletter to all clinical staff. Serious 5 Medication resulting in reaction and tinnitus later reported. Review found that this error occurred because a ‘medication added’ label was not attached to the syringe containing the antibiotic. There was also a delay between the preparation and administration. Review recommended: requirement for ‘medication label fastened securely to syringe. Use of second medication added label required when titrating (rate/dose adjustment) inform family when administering medications staff education. Action plan almost complete – one recommendation in progress. Serious 4a Missed diagnosis – permanent harm resulted. Review found that clinical examination findings were not compatible with the diagnosis, and that it was likely that a change had occurred in the clinical presentation subsequently. Review recommended: apology to the patient and provision of the report risk of error continue to be emphasised in training to staff. Action plan complete and closed.
Serious-and-Sentinel-Events-Cases-2008_09.docx