Sentinel 4F 1 Urgent readmission within Family concerns were not acted on All senior nurses reminded to Discussed at senior nurse two hours of discharge. upon discharge. include family members in forum completed. – Patient subsequently died. discussions on discharge Lack of clarity for family around care Discussed at surgical planning, to clarify questions / treatment received. governance forum. from family in writing and to Case to be presented at a organise further meeting if governance meeting with requested by family. recommendations for of Review communication with all families to be present at surgical teams. ward rounds. having family present at ward rounds. Sentinel 4G 1 Cross infection in single unit Process not in place to ensure all Ensure personal protective Unit manager enforcing use between seven patients. multiuse equipment routinely equipment is implemented for of personal protective Subsequent infection and cleaned between patients. multi-resistant patients. equipment appropriate. sepsis in one patient resulting Hand hygiene education by Infection Review and modify cleaning Cleaning process review in in death. Control nurse had not been effective process for all equipment that is progress. in preventing further cross infection. multiuse to ensure it is Hand hygiene coordinator appropriately cleaned. appointed and hand Raise hygiene’ awareness. hygiene project currently ‘hand implemented organisation wide. Serious 5 2 Incorrect administration of Correct protocol not accessed. Review process for accessing Education about accessing medication requiring antidote protocols and administering protocols and administering Correct process not followed to and transfer to Coronary controlled drugs with nursing controlled drugs completed administer controlled drug. Care Unit. staff. January 2009. Discrepancy between nursing and Full recovery. Nursing and pharmacy to review Pharmacy currently pharmacy protocols for and amend polices so they align. reviewing and modifying administration of controlled drugs. policies. Documentation and Inaccurate documentation of dose communication re administration In progress plus additional given in notes. of medication to be incorporated / orientation’ ‘socialisation into orientation training for new one-day programme graduates. run for new nursing staff with focus on expectations and communication.
Sentinel 4F 1 Urgent readmission within two hours of discharge. Patient subsequently died. Family concerns were not acted on upon discharge. Lack of clarity for family around care / treatment received. All senior nurses reminded to include family members in discussions on discharge planning, to clarify questions from family in writing and to organise further meeting if requested by family. Review communication with all surgical teams. having family present at ward rounds. Discussed at senior nurse forum – completed. Discussed at surgical governance forum. Case to be presented at a governance meeting with recommendations for of families to be present at ward rounds. Sentinel 4G 1 Cross infection in single unit between seven patients. Subsequent infection and sepsis in one patient resulting in death. Process not in place to ensure all multiuse equipment routinely cleaned between patients. Hand hygiene education by Infection Control nurse had not been effective in preventing further cross infection. Ensure personal protective equipment is implemented for multi-resistant patients. Review and modify cleaning process for all equipment that is multiuse to ensure it is appropriately cleaned. Raise ‘hand hygiene’ awareness. Unit manager enforcing use of personal protective equipment appropriate. Cleaning process review in progress. Hand hygiene coordinator appointed and hand hygiene project currently implemented organisation wide. Serious 5 2 Incorrect administration of medication requiring antidote and transfer to Coronary Care Unit. Full recovery. Correct protocol not accessed. Correct process not followed to administer controlled drug. Discrepancy between nursing and pharmacy protocols for administration of controlled drugs. Inaccurate documentation of dose given in notes. Review process for accessing protocols and administering controlled drugs with nursing staff. Nursing and pharmacy to review and amend polices so they align. Documentation and communication re administration of medication to be incorporated into orientation training for new graduates. Education about accessing protocols and administering controlled drugs completed January 2009. Pharmacy currently reviewing and modifying policies. In progress plus additional ‘socialisation / orientation’ one-day programme run for new nursing staff with focus on expectations and communication.
Serious-and-Sentinel-Events-Cases-2008_09.docx