Serious 4b 2 Patient’s condition Review in progress. deteriorating. Slow response from medical team to review. Serious 11 2 Physical assault by patient Ensure appropriate accommodation Ensure discharge planning In progress. whilst on leave from inpatient on discharge. process considers appropriate facility. discharge accommodation. Serious 4b 2 Patient had x-ray of hand Review in progress. and there was a delay in taking action of the result. Had fractured hand. Serious 6 2 Patient fall with resulting Review in progress. injury sustained. Serious 11 2 Patient had neurosurgical Drain very similar in colour to other Change drain type to coloured In progress. drain removed in error. drains in use, making it easy to to reduce risk of similar event Patient had to return to remove incorrect drain. recurring. theatre for re-insertion. Serious 4a 2 Delayed diagnosis and No follow-up provided was to be – assessment of patient due to discussed at mortality and morbidity self discharge and meeting. incomplete assessment by staff. Serious 4g 2 Communication issues Review in progress. between departments. Serious 11 2 Wrong body uplifted from The funeral director did not check Review mortuary procedures In progress. mortuary. the identification of the body being relating to persons depositing or uplifted. The procedures describing removing bodies plus DHB Care the process for persons uplifting of deceased policy and bodies are not readily accessible at procedure. the point of transfer in the mortuary Draft mortuary procedures to be and have not been circulated to circulated to funeral directors for relevant parties such as funeral comment. Controlled copies of directors. This contributed to the final procedures to be confusion regarding who was distributed to funeral directors. responsible for identifying the body.
Serious 4b 2 Patient’s condition deteriorating. Slow response from medical team to review. Review in progress. Serious 11 2 Physical assault by patient whilst on leave from inpatient facility. Ensure appropriate accommodation on discharge. Ensure discharge planning process considers appropriate discharge accommodation. In progress. Serious 4b 2 Patient had x-ray of hand and there was a delay in taking action of the result. Had fractured hand. Review in progress. Serious 6 2 Patient fall with resulting injury sustained. Review in progress. Serious 11 2 Patient had neurosurgical drain removed in error. Patient had to return to theatre for re-insertion. Drain very similar in colour to other drains in use, making it easy to remove incorrect drain. Change drain type to coloured to reduce risk of similar event recurring. In progress. Serious 4a 2 Delayed diagnosis and assessment of patient due to self discharge and incomplete assessment by staff. No follow-up provided – was to be discussed at mortality and morbidity meeting. Serious 4g 2 Communication issues between departments. Review in progress. Serious 11 2 Wrong body uplifted from mortuary. The funeral director did not check the identification of the body being uplifted. The procedures describing the process for persons uplifting bodies are not readily accessible at the point of transfer in the mortuary and have not been circulated to relevant parties such as funeral directors. This contributed to the confusion regarding who was responsible for identifying the body. Review mortuary procedures relating to persons depositing or removing bodies plus DHB Care of deceased policy and procedure. Draft mortuary procedures to be circulated to funeral directors for comment. Controlled copies of final procedures to be distributed to funeral directors. In progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx