Serious 6 Patient fell and Patient mobilised independently without project completed and new risk assessments Completed. dislocated pelvis supervision. and education in place for staff. bone. Serious 6 Patient fell and Patient had medical condition that likely Introduction of escalation flow chart to expedite Completed. fractured contributed to fall. transfers to medical wards and consistency of shoulder. information used to assess requirement for general hospital admission. Serious 11 Patient’s cardiac Review concluded that no issue with No root causes found. Completed arrest not noticed alarms. Active resuscitation was initiated as alarm did not within seconds of arrest being noticed. activate in Referred to Coroner. theatre. Patient died later in ICU from other causes. Serious 12 Elective Review concluded no issues with care Consideration is given to extending the hospital flu Completed. admission to provided. vaccination programme to offer the flu vaccine to hospital. Patient high-risk patient groups. developed flu in hospital and died. Sentinel 1 Patient had The patient identity was not verified by To develop a policy on patient identification. Policy to procedure (PICC two members of staff to ensure correct have implementation plan agreed as part of process. Line patient was transferred to radiology. – To develop a patient verification handover process peripherally process to include patient not to be transferred inserted central until process is completed. Process to include phone catheter – verification checks. inserted) that was for another To implement the WHO Surgical Safety Checklist for Completed patient. Radiology Interventions Only process.
Serious 6 Patient fell and dislocated pelvis bone. Patient mobilised independently without supervision. project completed and new risk assessments and education in place for staff. Completed. Serious 6 Patient fell and fractured shoulder. Patient had medical condition that likely contributed to fall. Introduction of escalation flow chart to expedite transfers to medical wards and consistency of information used to assess requirement for general hospital admission. Completed. Serious 11 Patient’s cardiac arrest not noticed as alarm did not activate in theatre. Patient died later in ICU from other causes. Review concluded that no issue with alarms. Active resuscitation was initiated within seconds of arrest being noticed. Referred to Coroner. No root causes found. Completed Serious 12 Elective admission to hospital. Patient developed flu in hospital and died. Review concluded no issues with care provided. Consideration is given to extending the hospital flu vaccination programme to offer the flu vaccine to high-risk patient groups. Completed. Sentinel 1 Patient had procedure (PICC Line – peripherally inserted central catheter – inserted) that was for another patient. The patient identity was not verified by two members of staff to ensure correct patient was transferred to radiology. To develop a policy on patient identification. Policy to have implementation plan agreed as part of process. To develop a patient verification handover process process to include patient not to be transferred until process is completed. Process to include phone verification checks. To implement the WHO Surgical Safety Checklist for Radiology Interventions Only process. Completed
SSE-cases-2010-11-FINALv1.docx