Serious 9 Unwitnessed assault Risk assessment and management Nil recommendations made. Referred to Police. on an inpatient by co plan appropriate. patient. Sustained multiple injuries resulting in permanent disability. Serious 4D IV drug leaked into IV cannula insertion difficult as Feedback to nursing staff on Completed. tissue, requiring patient having a fit. IV protocol Phenytoin infusion (drug to treat fit) surgery. including flushing line was followed and selection of IV insertion site. and the line was deemed patent. As the patient was suffering a fit, the line was secured with a bandage, thus unable to observe. Two hours later, the IV site was checked and leak was discovered. Serious 6 Inpatient fall resulting Elderly patient who required in fractured shoulder. assistance to mobilise got out of bed to go to bathroom, without calling for assistance. Sentinel 6 Inpatient fall resulting Appropriate assessment made but in subsequent death. still fell. The apparent cause of the fall was multi-factorial, and not necessarily attributed to a single cause. Sentinel 6 Inpatient fall resulting The fall was not the root cause of the in fractured hip and death. subsequent No formal falls risk assessment undertaken. Reporting requirements not met.
Serious 9 Unwitnessed assault on an inpatient by co patient. Sustained multiple injuries resulting in permanent disability. Risk assessment and management plan appropriate. Nil recommendations made. Referred to Police. Serious 4D IV drug leaked into tissue, requiring surgery. IV cannula insertion difficult as patient having a fit. IV protocol including flushing line was followed and the line was deemed patent. As the patient was suffering a fit, the line was secured with a bandage, thus unable to observe. Two hours later, the IV site was checked and leak was discovered. Feedback to nursing staff on Phenytoin infusion (drug to treat fit) and selection of IV insertion site. Completed. Serious 6 Inpatient fall resulting in fractured shoulder. Elderly patient who required assistance to mobilise got out of bed to go to bathroom, without calling for assistance. Sentinel 6 Inpatient fall resulting in subsequent death. Appropriate assessment made but still fell. The apparent cause of the fall was multi-factorial, and not necessarily attributed to a single cause. Sentinel 6 Inpatient fall resulting in fractured hip and subsequent The fall was not the root cause of the death. No formal falls risk assessment undertaken. Reporting requirements not met.
SSE-cases-2010-11-FINALv1.docx