Serious 4A Two patients’ As above. As above. biopsy samples were mixed up resulting in incorrect diagnoses for both patients involved. Serious 11 Patient assaulted Review completed. Scheduled for panel 2012. a third person whilst being transported to hospital by family. Serious 11 Patient attempted Observation levels were not clearly Clarity on observation procedure given to all ward Completed self-harm and communicated or promptly enacted. staff and confirmation of responsibility for handover March 2011 sustained minor between shifts. Service user was not sighted by morning injuries. April 2011. staff at commencement of shift. Handover procedure has been amended to including the requirement for staff to sight all service users New RN not aware RNs can increase immediately following handover. level of observation without medical officer approval if risk identified. All new nurses to have identified preceptors and training to be provided to increase number of available preceptors. Training continues through Ongoing. 2011 and preceptorship and available preceptors are monitored via the Clinical Nurse Director and Clinical Governance Forum. Serious 11 Self-harm The immediate management and Review the Levels of observation procedure to Ongoing resulting in communication of identified escalating include: The communication and management plan risk directly following assessment, was process between staff, directly following assessment injuries. not adequate.. indicating increased risk.
Serious 4A Two patients’ biopsy samples were mixed up resulting in incorrect diagnoses for both patients involved. As above. As above. Serious 11 Patient assaulted a third person whilst being transported to hospital by family. Review completed. Scheduled for panel 2012. Serious 11 Patient attempted self-harm and sustained minor injuries. Observation levels were not clearly communicated or promptly enacted. Service user was not sighted by morning staff at commencement of shift. New RN not aware RNs can increase level of observation without medical officer approval if risk identified. Clarity on observation procedure given to all ward staff and confirmation of responsibility for handover between shifts. Handover procedure has been amended to including the requirement for staff to sight all service users immediately following handover. All new nurses to have identified preceptors and training to be provided to increase number of available preceptors. Training continues through 2011 and preceptorship and available preceptors are monitored via the Clinical Nurse Director and Clinical Governance Forum. Completed March 2011 April 2011. Ongoing. Serious 11 Self-harm resulting in injuries. The immediate management and communication of identified escalating risk directly following assessment, was not adequate.. Review the Levels of observation procedure to include: The communication and management plan process between staff, directly following assessment indicating increased risk. Ongoing
SSE-cases-2010-11-FINALv1.docx