Sentinel 4a 1 A patient died in hospital A CT abdomen was delayed and A process for clear, effective, written handover Process agreed. due to a delay in a sub-phrenic abscess, due to between consultants, especially at weekends diagnosis and treatment. ruptured gallbladder, was only should be developed. discovered some days admission. There was a misunderstanding between the consultant and house surgeon as well as difficulties in communication between surgical consultants and between the surgical and medical teams and the family. West Coast Serious Event code* SAC 1/SAC 2/ Description of Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Serious 11 N/c Sterile cannulated drill guide found to be guide had not been Steps implemented to improve contaminated prior to use on patient. processed correctly. checking system. Serious 10 N/c Delay in care provided to patient; transfer Rare combination of events as Need to investigate compatibility issues Ongoing. of trauma patient requiring tertiary level both South Island tertiary regarding electronic reports between all ICU delayed due to combination of hospitals unacceptable to accept tertiary hospitals that are potential weather, secondary tertiary hospital transfers due to weather. recipients of patients from West unable to read electronic radiology report so unable to accept patient (although this was eventually sorted out), and retrieval team undertaking another transfer. Canterbury
Sentinel 4a 1 A patient died in hospital due to a delay in diagnosis and treatment. A CT abdomen was delayed and a sub-phrenic abscess, due to ruptured gallbladder, was only discovered some days admission. There was a misunderstanding between the consultant and house surgeon as well as difficulties in communication between surgical consultants and between the surgical and medical teams and the family. A process for clear, effective, written handover between consultants, especially at weekends should be developed. Process agreed. West Coast Serious or sentinel Event code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of Review findings Recommendations/ actions Follow up Serious 11 N/c Sterile cannulated drill guide found to be contaminated prior to use on patient. guide had not been processed correctly. Steps implemented to improve checking system. Serious 10 N/c Delay in care provided to patient; transfer of trauma patient requiring tertiary level ICU delayed due to combination of weather, secondary tertiary hospital unable to read electronic radiology report so unable to accept patient (although this was eventually sorted out), and retrieval team undertaking another transfer. Rare combination of events as both South Island tertiary hospitals unacceptable to accept transfers due to weather. Need to investigate compatibility issues regarding electronic reports between all tertiary hospitals that are potential recipients of patients from West Ongoing. Canterbury
Serious-and-Sentinel-Events-Cases-2008_09.docx