Counties Manukau District Health www.cmdhb.org.nz Serious or Event Description of Review findings Recommendations/actions Follow-up sentinel code Serious 1 CT scan performed on Name label mistakenly attached Review process of storing patient A Patient Identification Group patient in error. to another patient’s CT request identification labels and develop has been established to review form. interventions to improve safety of incidents involving system. misidentification of patients. Investigate the potential for This group is currently working electronic requests for procedures. on better systems for storing and managing labels. An electronic solution is not currently feasible, but is likely to be developed in the next 24 months. The trial is investigating ways of modifying internal referral processes for procedures. Serious 1 Gastroscopy procedure Name label mistakenly attached Review process of storing patient The Patient Identification was completed on a to another patient’s form due to: identification labels and develop Group is working on a better patient when for interventions to improve safety of system for storing and practice of storing patient another patient. The system. managing labels. identification labels for multiple patient then required a patients in a single location Develop and implement a A modified Health second procedure to Gastroenterology Procedural Checklist. Organization (WHO) Time Out reinsert a stomach tube process of writing most procedures checklist has been (nasojejeunal tube) referrals at the end of the ward Develop standard operating procedures implemented in Endoscopy. resulting in a gastric round for Gastroenterology Intervention perforation. An Endoscopy Quality Group absence of a clearly defined has been established to process, defined roles, use of develop standard operating Out’ in establishing patient ‘Time procedures. identity.
Counties Manukau District Health www.cmdhb.org.nz Serious or sentinel Event code Description of Review findings Recommendations/actions Follow-up Serious 1 CT scan performed on patient in error. Name label mistakenly attached to another patient’s CT request form. Review process of storing patient identification labels and develop interventions to improve safety of system. Investigate the potential for electronic requests for procedures. A Patient Identification Group has been established to review incidents involving misidentification of patients. This group is currently working on better systems for storing and managing labels. An electronic solution is not currently feasible, but is likely to be developed in the next 24 months. The is investigating ways of modifying internal referral processes for procedures. Serious 1 Gastroscopy procedure was completed on a patient when for another patient. The patient then required a second procedure to reinsert a stomach tube (nasojejeunal tube) resulting in a gastric perforation. Name label mistakenly attached to another patient’s form due to: practice of storing patient identification labels for multiple patients in a single location process of writing most referrals at the end of the ward round absence of a clearly defined process, defined roles, use of ‘Time Out’ in establishing patient identity. Review process of storing patient identification labels and develop interventions to improve safety of system. Develop and implement a Gastroenterology Procedural Checklist. Develop standard operating procedures for Gastroenterology Intervention The Patient Identification Group is working on a better system for storing and managing labels. A modified Health Organization (WHO) Time Out procedures checklist has been implemented in Endoscopy. An Endoscopy Quality Group has been established to develop standard operating procedures. trial
SSE-cases-2010-11-FINALv1.docx