Sentinel 4A 1 Elderly man admitted to Failure to recognise acuity of Patient admitted to community to Physiologically unstable community hospital by patient’s condition by medical and have minimum three sets of vital patient protocol currently general practitioner. Lack of nursing signs recorded in first 24 hours. reviewed for recognition of physiological implementation in Vital signs not consistently carried Physiologically unstable patient deterioration delayed community hospitals. out and no fluid balance chart kept. protocol (adapted for community admission to main hospital setting) to be followed for any All registered staff in both where patient died shortly patient assessed as unstable. community hospitals after. completed training in vital Education for nursing staff to sign recording and review accurate and timely monitoring to recognise recording and monitoring of vital clinical deterioration. signs and fluid balance. Serious 4A 2 Eye disease in premature Service reliant on single Recall programme for all babies All babies were recalled baby not picked up at ophthalmologist causing problems previously screened by doctor and re-examined. screening resulting in when covering leave. undertaken with assistance from Recruitment underway and significantly impaired vision in Neonatal Unit Limited peer review / audit. job description updated. one eye. New paediatric ophthalmologist National auditing being recruited and job completed. description to specify clinical competencies in greater detail. Develop system for clinical audit of screening process. Serious 4C 2 Serious tissue injury to baby’s Fluid balance chart doesn’t facilitate Redesign current paediatric fluid New fluid balance chart hand from intravenous (IV) documentation of IV checks. balance chart. implemented 01/07/2009. line requiring surgery. Good Scoring tool not used to assess IV Incorporate scoring tools into Scoring included in recovery. site. new fluid balance chart. new fluid balance chart. Splinting used in paediatric patients Develop standards for IV Standards for IV securing to secure the IV site hides splinting and securing for and splinting in children development of complications. paediatric patients. developed and implemented.
Sentinel 4A 1 Elderly man admitted to community hospital by general practitioner. Lack of recognition of physiological deterioration delayed admission to main hospital where patient died shortly after. Failure to recognise acuity of patient’s condition by medical and nursing Vital signs not consistently carried out and no fluid balance chart kept. Patient admitted to community to have minimum three sets of vital signs recorded in first 24 hours. Physiologically unstable patient protocol (adapted for community setting) to be followed for any patient assessed as unstable. Education for nursing staff to review accurate and timely recording and monitoring of vital signs and fluid balance. Physiologically unstable patient protocol currently reviewed for implementation in community hospitals. All registered staff in both community hospitals completed training in vital sign recording and monitoring to recognise clinical deterioration. Serious 4A 2 Eye disease in premature baby not picked up at screening resulting in significantly impaired vision in one eye. Service reliant on single ophthalmologist causing problems when covering leave. Limited peer review / audit. Recall programme for all babies previously screened by doctor undertaken with assistance from Neonatal Unit New paediatric ophthalmologist being recruited and job description to specify clinical competencies in greater detail. Develop system for clinical audit of screening process. All babies were recalled and re-examined. Recruitment underway and job description updated. National auditing completed. Serious 4C 2 Serious tissue injury to baby’s hand from intravenous (IV) line requiring surgery. Good recovery. Fluid balance chart doesn’t facilitate documentation of IV checks. Scoring tool not used to assess IV site. Splinting used in paediatric patients to secure the IV site hides development of complications. Redesign current paediatric fluid balance chart. Incorporate scoring tools into new fluid balance chart. Develop standards for IV splinting and securing for paediatric patients. New fluid balance chart implemented 01/07/2009. Scoring included in new fluid balance chart. Standards for IV securing and splinting in children developed and implemented.
Serious-and-Sentinel-Events-Cases-2008_09.docx