Sentinel 3 Patient had Patient’s procedure did not stop when Review implementation process of the Waikato DHB retained swab incorrect count was notified to the team. policy: Surgical for Swabs, Sharps and following cardiac Instruments. procedure. Discussion to take place regarding implementing a Required Out/Stop’ command when incomplete count is ‘Time additional notified. If agreed, this action to be added to Surgical procedure to Count for Swabs Sharps and Instruments policy. remove swab. Implement the WHO Surgical Safety Checklist in department. The operating surgeon should also verbally acknowledge they have the scrub practitioner . Sentinel 1 Surgical Ineffective quality control processes Review laboratory process/work flow (in consultation procedure being in place/implemented and with Waikato DHB process specialist). performed on environmental issues led to biopsy Review the current quality monitoring and reporting wrong patient due tissue belonging to Patient B being systems within laboratory and implement any to two patients’ placed in Patient A cassette during recommendations. biopsy samples laboratory process. being mixed up, Initiate creation of a regional networking quality This resulted in patient having surgical and incorrect model (with a focus on learning/sharing of best procedure meant for another patient. diagnoses for practice) for this laboratory. both patients Revise/produce procedure documentation regarding involved. independent double checks on biopsy specimens. Review practice of processing like specimens (eg, breast) through laboratory. Review options for technical and managerial leadership structures in this laboratory.
Sentinel 3 Patient had retained swab following cardiac procedure. Required additional procedure to remove swab. Patient’s procedure did not stop when incorrect count was notified to the team. Review implementation process of the Waikato DHB policy: Surgical for Swabs, Sharps and Instruments. Discussion to take place regarding implementing a ‘Time Out/Stop’ command when incomplete count is notified. If agreed, this action to be added to Surgical Count for Swabs Sharps and Instruments policy. Implement the WHO Surgical Safety Checklist in department. The operating surgeon should also verbally acknowledge they have the scrub practitioner . Sentinel 1 Surgical procedure performed on wrong patient due to two patients’ biopsy samples being mixed up, and incorrect diagnoses for both patients involved. Ineffective quality control processes being in place/implemented and environmental issues led to biopsy tissue belonging to Patient B being placed in Patient A cassette during laboratory process. This resulted in patient having surgical procedure meant for another patient. Review laboratory process/work flow (in consultation with Waikato DHB process specialist). Review the current quality monitoring and reporting systems within laboratory and implement any recommendations. Initiate creation of a regional networking quality model (with a focus on learning/sharing of best practice) for this laboratory. Revise/produce procedure documentation regarding independent double checks on biopsy specimens. Review practice of processing like specimens (eg, breast) through laboratory. Review options for technical and managerial leadership structures in this laboratory.
SSE_cases_2010_11_FINALv1.docx