Serious 4c 3 Patient deterioration and Early warning scoring inconsistent Staff knowledge and assessment Staff training increased in delayed assessment. resulting in delayed assessment. skills using the early warning the service and assessment score reviewed. skills reviewed. Emergency call not made when the indicated it should have, despite Reinforcement of emergency doctor in attendance. reviewed with staff. Patient required transferred to ICU after initial stabilisation and had prolonged recovery. Serious 4d 3 Medication administration Morphine elixir via an IV line instead Best practice not followed. Case review undertaken error. of a gastric tube. and used in teaching. Increased supervision required. Medication checking process to the Equipment change Equipment changed and staff bed side inadequate. actioned. trained to identify correct Dedicated syringe for gastric tubes administration practice. not used in administration process. Sentinel 4d 2 Unexpected death following Underwent an elective inguinal Pre discharge assessment Service continuing to review elective surgery. hernia repair. Discharged home the requirements reviewed with staff. this incident. next day. At home collapsed and died. Autopsy identified complication surgery. Serious 11 2 Prolonged infection outbreak. Prolonged ESBL outbreak with Extensive outbreak management Services continuing to colonisation of a number of patients. plan has been in place. review this situation to ESBL has contributed to infections Reviewed by CDC. ensure systems issues are which may have contributed to addressed. Intensive and staff education deaths of a few patients. programme in place. Sentinel 4d 1 Unexpected death from Admitted for treatment of myocardial Administration practice of Continuous education complications of infarction with Clexane and Aspirin. Clexane reviewed as process. anticoagulation therapy. Deteriorated and transferred to ICU. appropriate. CT scan showed bleeding from Case review used in staff inferior epigastric artery associated teaching to increase awareness with large rectus sheath of recommended sites for haematoma. Transferred to the administration in patient vascular service. Deceased. teaching.
Serious 4c 3 Patient deterioration and delayed assessment. Early warning scoring inconsistent resulting in delayed assessment. Emergency call not made when the indicated it should have, despite doctor in attendance. Patient required transferred to ICU after initial stabilisation and had prolonged recovery. Staff knowledge and assessment skills using the early warning score reviewed. Reinforcement of emergency reviewed with staff. Staff training increased in the service and assessment skills reviewed. Serious 4d 3 Medication administration error. Morphine elixir via an IV line instead of a gastric tube. Medication checking process to the bed side inadequate. Dedicated syringe for gastric tubes not used in administration process. Best practice not followed. Increased supervision required. Equipment changed and staff trained to identify correct administration practice. Case review undertaken and used in teaching. Equipment change actioned. Sentinel 4d 2 Unexpected death following elective surgery. Underwent an elective inguinal hernia repair. Discharged home the next day. At home collapsed and died. Autopsy identified complication surgery. Pre discharge assessment requirements reviewed with staff. Service continuing to review this incident. Serious 11 2 Prolonged infection outbreak. Prolonged ESBL outbreak with colonisation of a number of patients. ESBL has contributed to infections which may have contributed to deaths of a few patients. Extensive outbreak management plan has been in place. Reviewed by CDC. Intensive and staff education programme in place. Services continuing to review this situation to ensure systems issues are addressed. Sentinel 4d 1 Unexpected death from complications of anticoagulation therapy. Admitted for treatment of myocardial infarction with Clexane and Aspirin. Deteriorated and transferred to ICU. CT scan showed bleeding from inferior epigastric artery associated with large rectus sheath haematoma. Transferred to the vascular service. Deceased. Administration practice of Clexane reviewed as appropriate. Case review used in staff teaching to increase awareness of recommended sites for administration in patient teaching. Continuous education process.
Serious-and-Sentinel-Events-Cases-2008_09.docx