August 5 1 Patient admitted to Patient was treated for the initial The emergency department has Policy in and 2008 emergency department bleeding stomach ulcer, but implemented a policy ensuring the safe education of clinical with a hip fracture. The developed further bleeding and prescribing of non-steroidal inflammatory staff in the patient was treated and later died. medications to elderly patients. emergency discharged home, and department on the prescribed a policy has occurred inflammatory through the clinical medication for pain. The head of department. patient represented, with a bleeding stomach ulcer and subsequently died. Capital & Coast Serious code* SAC 1/SAC 2/ Description of event Review findings Recommendations/ actions Follow up or (see codes N/C (not sentinel below) classified) Sentinel 11 1 Possible anaphylactic The review team found that Review recommended: Action plan in reaction to antibiotic. clinical management was progress. improving the system for medication Patient deceased. appropriate but that the system alerts for medication alerts did not feedback of learning from this event to provide a clear, current and staff. accessible history of medication sensitivities. Serious 4C 2 Patient with peripheral The review team found issues Review recommended: Action plan in central line developed across the multidisciplinary team progress. staff education re post insertion care and clot in arm relating to peripheral central line management management. improved information reinstate steering group to provide oversight, audit, monitor and respond to issues ongoing.
August 2008 5 1 Patient admitted to emergency department with a hip fracture. The patient was treated and discharged home, and prescribed a inflammatory medication for pain. The patient represented, with a bleeding stomach ulcer and subsequently died. Patient was treated for the initial bleeding stomach ulcer, but developed further bleeding and later died. The emergency department has implemented a policy ensuring the safe prescribing of non-steroidal inflammatory medications to elderly patients. Policy in and education of clinical staff in the emergency department on the policy has occurred through the clinical head of department. Capital & Coast Serious or sentinel code* (see codes below) SAC 1/SAC 2/ N/C (not classified) Description of event Review findings Recommendations/ actions Follow up Sentinel 11 1 Possible anaphylactic reaction to antibiotic. Patient deceased. The review team found that clinical management was appropriate but that the system for medication alerts did not provide a clear, current and accessible history of medication sensitivities. Review recommended: improving the system for medication alerts feedback of learning from this event to staff. Action plan in progress. Serious 4C 2 Patient with peripheral central line developed clot in arm The review team found issues across the multidisciplinary team relating to peripheral central line management. Review recommended: staff education re post insertion care and management improved information reinstate steering group to provide oversight, audit, monitor and respond to issues ongoing. Action plan in progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx