Sentinel 5 Medication Critically unwell on admission with major Approved medication administration Safe Medicines Steering administration cardio-respiratory and other procedures reinforced with nurses across monitors safety Wrong medication the DHB. strategy initiatives, errors administered. trends and significant Nurse administered medications incidents. intended for another patient due to up with prescription sheet. The case has been referred to the Coroner (awaiting confirmed cause of death). Sentinel 5 Medication Prescription misread by the nurse External expert review of investigation Recommendations being administration error. administering medication. undertaken. implemented. Small dose was Patient unwell with major Review of practice for verbal Safe Medicines Steering prescribed, but respiratory and other co-morbidities. communication of unusually small (or Group monitors safety standard dose Due to very limited cardiovascular large) prescriptions to reduce the risk of strategy initiatives, errors administered. reserve this single dose was associated misreading error. trends and significant with circulatory failure, which was incidents. Implement national medication chart with unresponsive to treatment. pre-printed decimal point. The case has been referred to the Communication processes between Coroner (awaiting confirmed cause of clinical teams under review. death). Serious 5 Medication Adrenaline 0.5mg intramuscular Review of emergency protocols with prescription error. injection should have been prescribed doctor and nurses and competence 1mg of intravenous and administered. update. Adrenaline prescribed Patient experienced significant rise in Review of 777 (emergency) call and administered for blood pressure. Transferred to intensive procedure with junior staff. patient having an care unit (ICU). Cardiac impact noted. anaphylactic (allergic Training exercises emergency response) event. Patient has had no long-term adverse algorithms for cardiac arrest and effects. anaphylaxis scenarios.
Sentinel 5 Medication administration Wrong medication administered. Critically unwell on admission with major cardio-respiratory and other Nurse administered medications intended for another patient due to with prescription sheet. The case has been referred to the Coroner (awaiting confirmed cause of death). Approved medication administration procedures reinforced with nurses across the DHB. Safe Medicines Steering monitors safety strategy initiatives, errors trends and significant incidents. Sentinel 5 Medication administration error. Small dose was prescribed, but standard dose administered. Prescription misread by the nurse administering medication. Patient unwell with major and other co-morbidities. Due to very limited cardiovascular reserve this single dose was associated with circulatory failure, which was unresponsive to treatment. The case has been referred to the Coroner (awaiting confirmed cause of death). External expert review of investigation undertaken. Review of practice for verbal communication of unusually small (or large) prescriptions to reduce the risk of misreading error. Implement national medication chart with pre-printed decimal point. Communication processes between clinical teams under review. Recommendations being implemented. Safe Medicines Steering Group monitors safety strategy initiatives, errors trends and significant incidents. Serious 5 Medication prescription error. 1mg of intravenous Adrenaline prescribed and administered for patient having an anaphylactic (allergic response) event. Adrenaline 0.5mg intramuscular injection should have been prescribed and administered. Patient experienced significant rise in blood pressure. Transferred to intensive care unit (ICU). Cardiac impact noted. Patient has had no long-term adverse effects. Review of emergency protocols with doctor and nurses and competence update. Review of 777 (emergency) call procedure with junior staff. Training exercises emergency algorithms for cardiac arrest and anaphylaxis scenarios. up respiratory
SSE-cases-2010-11-FINALv1.docx