MidCentral District Health www.midcentraldhb.govt.nz Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code* Serious 4A Fall resulting in fractured Fracture occurred prior to admission Colour, warmth and movement, and Completed. ankle prior to admission. during cardiac arrest when patient fell at sensation assessments to be completed Diagnosis delayed by four home. Was missed by staff for four early where potential bony injuries weeks. weeks until patient began mobilising. identified. immediately ordered and fracture noted. Sentinel 4C Patient found dead during No causal factors were identified in this Review the observation policy and Completed. morning round. incident. Regular overnight checking was procedure for the detail of the inspection completed, however more process that is required overnight. inspections are required. Serious 4D A haemodialysis machine The process flow for the management of Strengthen standards for process and Completed. was not disinfected prior to dirty to clean machines was not clear and flow of cleaning haemodialysis machines. connection to patient. No was impacted by inadequate storage Identify additional storage space to have identified harm to patient. space. clean and dirty machines separated. Serious 5 Incorrect dose of 10 times correct dose of Methadone Review and strengthen medication Completed. Methadone administered. given (ie, 50ml instead of 5ml) as a result checking process in specialist units when of the unfamiliarity with medication. staff are unfamiliar with medication. Intensive monitoring of patient was Explore options for obtaining lower required. strength medication (ie, 1mg/ml). Serious 3 Part of a surgical An additional instrument was brought into Revise and strengthen process to ensure Completed. instrument left in abdomen theatre during the surgery and was not all instruments used in surgery are following surgery. added to the count. included on count lists. Subsequently the patient was returned to theatre for removal of the retained instrument part.
MidCentral District Health www.midcentraldhb.govt.nz Serious or sentinel Event code* Description of event Review findings Recommendations/actions Follow-up Serious 4A Fall resulting in fractured ankle prior to admission. Diagnosis delayed by four weeks. Fracture occurred prior to admission during cardiac arrest when patient fell at home. Was missed by staff for four weeks until patient began mobilising. immediately ordered and fracture noted. Colour, warmth and movement, and sensation assessments to be completed early where potential bony injuries identified. Completed. Sentinel 4C Patient found dead during morning round. No causal factors were identified in this incident. Regular overnight checking was completed, however more inspections are required. Review the observation policy and procedure for the detail of the inspection process that is required overnight. Completed. Serious 4D A haemodialysis machine was not disinfected prior to connection to patient. No identified harm to patient. The process flow for the management of dirty to clean machines was not clear and was impacted by inadequate storage space. Strengthen standards for process and flow of cleaning haemodialysis machines. Identify additional storage space to have clean and dirty machines separated. Completed. Serious 5 Incorrect dose of Methadone administered. 10 times correct dose of Methadone given (ie, 50ml instead of 5ml) as a result of the unfamiliarity with medication. Intensive monitoring of patient was required. Review and strengthen medication checking process in specialist units when staff are unfamiliar with medication. Explore options for obtaining lower strength medication (ie, 1mg/ml). Completed. Serious 3 Part of a surgical instrument left in abdomen following surgery. Subsequently the patient was returned to theatre for removal of the retained instrument part. An additional instrument was brought into theatre during the surgery and was not added to the count. Revise and strengthen process to ensure all instruments used in surgery are included on count lists. Completed.
SSE-cases-2010-11-FINALv1.docx