Serious 4B Delays in referral Lack of processes in place to Process to be developed for return of care of patients and treatment of manage these high-risk patients. to Diabetes Podiatry service. patient. Patient [Waikato DHB subsequently stated that, following developed further review, this case was not a serious event. problems and However, this advice was received after the SSE required toe report was completed, and this case is included in the amputation. data within the main report.] Serious 4B to The process for checking and ensuring Share learning about this incident with all clinical and treat abnormality patient’s details are correct was not administrative staff, eg, at staff meeting. leading to patient carried out. Emphasise the practice of checking patient details developing and updating of patient label and information on cervical cancer. clinical records during each visit to ensure information current and correct. Mandatory use of electronic system for such details. Check and refresh patient details during each visit to ensure information current and correct. Audit of this compliance to take place.
Serious 4B Delays in referral and treatment of patient. Patient developed problems and required toe amputation. Lack of processes in place to manage these high-risk patients. Process to be developed for return of care of patients to Diabetes Podiatry service. [Waikato DHB subsequently stated that, following further review, this case was not a serious event. However, this advice was received after the SSE report was completed, and this case is included in the data within the main report.] Serious 4B to treat abnormality leading to patient developing cervical cancer. The process for checking and ensuring patient’s details are correct was not carried out. Share learning about this incident with all clinical and administrative staff, eg, at staff meeting. Emphasise the practice of checking patient details and updating of patient label and information on clinical records during each visit to ensure information current and correct. Mandatory use of electronic system for such details. Check and refresh patient details during each visit to ensure information current and correct. Audit of this compliance to take place.
SSE-cases-2010-11-FINALv1.docx