Sentinel 4D Cardiac arrest of Equipment became disconnected Anaesthetic Specialist, Registrar and At least once yearly educational ventilator-dependant during transfer. Technician education regarding the visits as part of departmental patient during MRI equipment utilised in this and other teaching to maintain familiarisation The incident was well managed scan. environments in Radiology. with this environment. with a successful outcome. Continuing ongoing advanced life support education be undertaken by all Anaesthesia and ICU staff. Serious 6 Inpatient fall resulting Investigation under way. in fracture of pelvis. Serious 6 Inpatient fall resulting Investigation way. in fractured knee. Sentinel 4F Death of a child with Baseline oxygen saturations when Children with chronic complex underlying patient was well were not conditions should have health conditions, available for reference. baseline oxygen saturations recorded which may or may not at intervals when well. Resuscitation status was not have been prevented clearly documented. Children with complex by earlier admission to medical problems the Intensive Care Paediatric Early Warning Scoring presenting with acute illness should Unit. System (PEWS) not currently in have their resuscitation status use, but is under development for reviewed in discussion with use in South Island DHBs. family/whanau and clearly documented. PEWS to take place on the children’s ward. Sentinel 4D Inadvertent Investigation under way. In the interim an organisational risk misplacement of a alert has been circulated to inform nasogastric tube staff of the potential risks of this resulting in patient procedure. death. Serious 6 Inpatient fall resulting Investigation under way. in fractured hip.
Sentinel 4D Cardiac arrest of ventilator-dependant patient during MRI scan. Equipment became disconnected during transfer. The incident was well managed with a successful outcome. Anaesthetic Specialist, Registrar and Technician education regarding the equipment utilised in this and other environments in Radiology. Continuing ongoing advanced life support education be undertaken by all Anaesthesia and ICU staff. At least once yearly educational visits as part of departmental teaching to maintain familiarisation with this environment. Serious 6 Inpatient fall resulting in fracture of pelvis. Investigation under way. Serious 6 Inpatient fall resulting in fractured knee. Investigation way. Sentinel 4F Death of a child with complex underlying health conditions, which may or may not have been prevented by earlier admission to the Intensive Care Unit. Baseline oxygen saturations when patient was well were not available for reference. Resuscitation status was not clearly documented. Paediatric Early Warning Scoring System (PEWS) not currently in use, but is under development for use in South Island DHBs. Children with chronic conditions should have baseline oxygen saturations recorded at intervals when well. Children with complex medical problems presenting with acute illness should have their resuscitation status reviewed in discussion with family/whanau and clearly documented. PEWS to take place on the children’s ward. Sentinel 4D Inadvertent misplacement of a nasogastric tube resulting in patient death. Investigation under way. In the interim an organisational risk alert has been circulated to inform staff of the potential risks of this procedure. Serious 6 Inpatient fall resulting in fractured hip. Investigation under way.
SSE-cases-2010-11-FINALv1.docx