Serious 5 Patient found Patient admitted to the Day All medications should be checked and Pharmacy staff to monitor. unconscious after Unit. Medicine reconciliation written on a medication chart prior to administration of did not before patient’s transfer to the ward from the day unit. If morning medications, surgery. RMO prescribed this cannot be completed, then which patient should medications from patient’s medications may have to be withheld and not have been own medication card, the patient monitored until medicine prescribed, and however, the reconciliation is completed. required transfer to medications Education regarding blood pressure and Conducted. CCU. Patient made a had been discontinued some anti-hypertensive medications to be full recovery. time ago. conducted. Serious 4B Failure to make Electronic discharge Tutorial for RMOs on the correct use of Ongoing. outpatient appointment summary stated outpatient the follow-up section of the electronic resulting in a delay in appointment to be made in discharge summary. treatment. one week; however, this was not written in the ‘follow-up appointments to be made’ section, and was overlooked by administration staff. An audit of discharge summaries showed inconsistency in recording follow-up appointments. Serious 6 Admitted to surgical No evidence of written or Written copy of patient care instructions Template for instructions ward, as a blistery verbal instructions given by must be to patient prior to discharge. developed March 2011. rash had developed clinic regarding plaster care All verbal instructions given to patient under a leg plaster. and symptoms to look out must be listed in patient notes. While mobilising in the for. New falls risk assessment tool All staff on the surgical ward to have an ward, patient fell and introduced and end of bed falls No falls risk care plan understanding and awareness of the new fractured a hip, care plan implemented April 2011. implemented on admission. Falls Injury Prevention Standard by 1 April requiring surgery. 2011.
Serious 5 Patient found unconscious after administration of morning medications, which patient should not have been prescribed, and required transfer to CCU. Patient made a full recovery. Patient admitted to the Day Unit. Medicine reconciliation did not before patient’s surgery. RMO prescribed medications from patient’s own medication card, however, the medications had been discontinued some time ago. All medications should be checked and written on a medication chart prior to transfer to the ward from the day unit. If this cannot be completed, then medications may have to be withheld and the patient monitored until medicine reconciliation is completed. Education regarding blood pressure and anti-hypertensive medications to be conducted. Pharmacy staff to monitor. Conducted. Serious 4B Failure to make outpatient appointment resulting in a delay in treatment. Electronic discharge summary stated outpatient appointment to be made in one week; however, this was not written in the ‘follow-up appointments to be made’ section, and was overlooked by administration staff. An audit of discharge summaries showed inconsistency in recording follow-up appointments. Tutorial for RMOs on the correct use of the follow-up section of the electronic discharge summary. Ongoing. Serious 6 Admitted to surgical ward, as a blistery rash had developed under a leg plaster. While mobilising in the ward, patient fell and fractured a hip, requiring surgery. No evidence of written or verbal instructions given by clinic regarding plaster care and symptoms to look out for. No falls risk care plan implemented on admission. Written copy of patient care instructions must be to patient prior to discharge. All verbal instructions given to patient must be listed in patient notes. All staff on the surgical ward to have an understanding and awareness of the new Falls Injury Prevention Standard by 1 April 2011. Template for instructions developed March 2011. New falls risk assessment tool introduced and end of bed falls care plan implemented April 2011.
SSE-cases-2010-11-FINALv1.docx