Serious 6 Patient fell and Patient mobilised independently without learning of this event with nursing and medical Ongoing fractured hip. supervision. staff including implication of practice about Surgery required management of the specific needs of a confused and patient elderly patient with physical limitations and deteriorated in an unfamiliar environment of a hospital. following surgery Implement the falls management practices to area and died. Completed Serious 6 Patient fell whilst Patient while in a confused and As a result of this incident the following actions were mobilising disorientated state pushed a table aside, taken: independently. mobilised independently and fell. all tables fitted with brakes Condition Completed. deteriorated and ward continues to and evaluate different patient died equipment resources to minimise falls, including current use of exit alarms and pressure mats/cushion. falls project completed and new risk Completed. assessments and education in place for staff. Serious 6 Patient fell and hit The patient was not sufficiently stable on Falls project completed and new risk assessments Completed. head. Condition feet, due to clinical condition and education in place for staff. deteriorated Audits completed to ensure compliance with falls following fall and Completed. assessment requirements. patient died Serious 6 Patient fell and No root causes found. Other learning needs identified: fractured hip. Review knowledge of care planning process and Required surgery. timely/accurate completion of documentation – Condition including the process of handover/completion of deteriorated after information between shifts. surgery, and patient died. Serious 6 Patient fell from All appropriate actions pre and post fall Review supervision of compromised patients whilst in bed and were taken. bed. sustained a head injury and died.
Serious 6 Patient fell and fractured hip. Surgery required and patient deteriorated following surgery and died. Patient mobilised independently without supervision. learning of this event with nursing and medical staff including implication of practice about management of the specific needs of a confused elderly patient with physical limitations and in an unfamiliar environment of a hospital. Implement the falls management practices to area Ongoing Completed Serious 6 Patient fell whilst mobilising independently. Condition deteriorated and patient died Patient while in a confused and disorientated state pushed a table aside, mobilised independently and fell. As a result of this incident the following actions were taken: all tables fitted with brakes ward continues to and evaluate different equipment resources to minimise falls, including current use of exit alarms and pressure mats/cushion. falls project completed and new risk assessments and education in place for staff. Completed. Completed. Serious 6 Patient fell and hit head. Condition deteriorated following fall and patient died The patient was not sufficiently stable on feet, due to clinical condition Falls project completed and new risk assessments and education in place for staff. Audits completed to ensure compliance with falls assessment requirements. Completed. Completed. Serious 6 Patient fell and fractured hip. Required surgery. Condition deteriorated after surgery, and patient died. No root causes found. Other learning needs identified: Review knowledge of care planning process and timely/accurate completion of documentation – including the process of handover/completion of information between shifts. Serious 6 Patient fell from bed and sustained a head injury and died. All appropriate actions pre and post fall were taken. Review supervision of compromised patients whilst in bed.
SSE-cases-2010-11-FINALv1.docx