Serious 6 1 Patient fall with resulting Patients confused and tried to Staff members to sign that they Implementation of falls injury sustained. This was mobilise without calling for staff have read and understood the project recommendations not diagnosed until patient assistance. Inpatient Falls Assessment and under way. was discharged from Management Protocol. No falls risk assessment. hospital. Patient readmitted Falls Protocol to be complied No falls mitigation strategies for surgery. with as evidenced by documented or implemented. compliance audit results. Neither the falls risk assessment nor Audit to be conducted by Q&R the mitigation strategies were Standards and Audit Facilitator. reassessed and revised after fall. Hourly rounds to be implemented as part of nursing model. risk management education to be provided to all staff. Serious 6 1 Patient fell and sustained Patients confused and tried to protocol to be complied Implementation of falls fractured hip and required mobilise without calling for staff with as evidenced by project recommendations surgical repair. assistance. compliance audit results. under way. Serious 6 1 Seven patient falls events. Falls project completed November Increase compliance with Implementation of 2009. existing Waikato DHB falls risk project recommendations minimisation strategies through under way. audit, education and nursing rounds. Ongoing monitoring of falls and compliance with organisational requirements. Serious 11 1 Outpatient suicide within RCA review in progress. seven days of last contact with service. Serious 4c 1 Patient was not monitored as RCA review in progress. per requirements.
Serious 6 1 Patient fall with resulting injury sustained. This was not diagnosed until patient was discharged from hospital. Patient readmitted for surgery. Patients confused and tried to mobilise without calling for staff assistance. No falls risk assessment. No falls mitigation strategies documented or implemented. Neither the falls risk assessment nor the mitigation strategies were reassessed and revised after fall. Staff members to sign that they have read and understood the Inpatient Falls Assessment and Management Protocol. Falls Protocol to be complied with as evidenced by compliance audit results. Audit to be conducted by Q&R Standards and Audit Facilitator. Hourly rounds to be implemented as part of nursing model. risk management education to be provided to all staff. Implementation of falls project recommendations under way. Serious 6 1 Patient fell and sustained fractured hip and required surgical repair. Patients confused and tried to mobilise without calling for staff assistance. protocol to be complied with as evidenced by compliance audit results. Implementation of falls project recommendations under way. Serious 6 1 Seven patient falls events. Falls project completed November 2009. Increase compliance with existing Waikato DHB falls risk minimisation strategies through audit, education and nursing rounds. Ongoing monitoring of falls and compliance with organisational requirements. Implementation of project recommendations under way. Serious 11 1 Outpatient suicide within seven days of last contact with service. RCA review in progress. Serious 4c 1 Patient was not monitored as per requirements. RCA review in progress.
Serious-and-Sentinel-Events-Cases-2008_09.docx