Serious 1 Wrong patient (cont’d) The son’s referral document was (cont’d) (cont’d) anaesthetised not available and not sighted at (cont’d). clinic. At the anaesthetic appointment, the consent/referral form was not viewed. Staff member competent in the referral onto the surgical booking list process. The surgical booking team had undergone significant changes including reorganisation of work allocation, staff turnover, increased workload and added pressure while recruitment occurred. Serious 4A Delay in diagnosis The discharge summary was not Sending copies of all X-ray results to the patient’s GP Completed. and treatment for completed. commenced in 2009. lung cancer that The Clinical Management of Test Results Digital radiology commenced in 2009, allowing easier was visible on a Completed. and Investigations procedure was not access to X-rays. chest X-ray taken in followed. July 2008. The Clinical Management of Test Results procedure Failure to arrange follow-up specifically has been reviewed and is now a policy. Completed. related to the chest X-ray result. Responsibilities have been clearly communicated. When admitted for the operation, the Explore options where information technology can In progress. patient’s previous chest X-ray result was assist clinical staff with results management to not noted. improve robustness. The patient’s X-ray result and advice Explore options for reviewing X-ray results that have concerning follow-up was not not been as read’ prior to 2009 and ‘marked In progress. communicated to the patient or noted in the implement the best solution. patient’s discharge summary to the patient’s GP. Serious 4B Patient presented Reviewing neurosurgeon to review the case Report pending. with back pain that notes and determine whether there are any [Commission comment: Advised by Taranaki DHB was diagnosed 48 actions to be taken to prevent delay in after report printed that this case, following review, hours later as an diagnosis. was not considered a serious or sentinel event.] epidural abscess.
Serious (cont’d) 1 (cont’d) Wrong patient anaesthetised (cont’d). (cont’d) The son’s referral document was not available and not sighted at clinic. At the anaesthetic appointment, the consent/referral form was not viewed. Staff member competent in the referral onto the surgical booking list process. The surgical booking team had undergone significant changes including reorganisation of work allocation, staff turnover, increased workload and added pressure while recruitment occurred. Serious 4A Delay in diagnosis and treatment for lung cancer that was visible on a chest X-ray taken in July 2008. The discharge summary was not completed. The Clinical Management of Test Results and Investigations procedure was not followed. Failure to arrange follow-up specifically related to the chest X-ray result. When admitted for the operation, the patient’s previous chest X-ray result was not noted. The patient’s X-ray result and advice concerning follow-up was not communicated to the patient or noted in the patient’s discharge summary to the patient’s GP. Sending copies of all X-ray results to the patient’s GP commenced in 2009. Digital radiology commenced in 2009, allowing easier access to X-rays. The Clinical Management of Test Results procedure has been reviewed and is now a policy. Responsibilities have been clearly communicated. Explore options where information technology can assist clinical staff with results management to improve robustness. Explore options for reviewing X-ray results that have not been ‘marked as read’ prior to 2009 and implement the best solution. Completed. Completed. Completed. In progress. In progress. Serious 4B Patient presented with back pain that was diagnosed 48 hours later as an epidural abscess. Reviewing neurosurgeon to review the case notes and determine whether there are any actions to be taken to prevent delay in diagnosis. Report pending. [Commission comment: Advised by Taranaki DHB after report printed that this case, following review, was not considered a serious or sentinel event.]
SSE_cases_2010_11_FINALv1.docx