Serious 4B Inappropriate Abdominal ascites tap performed despite Review of rationale with doctor. procedure performed. ultrasound stating no free fluid present. Reinforce communication with senior Deteriorated overnight with increasing consultant. abdominal pain and hypotension from wall haematoma. ICU admission. Discharged after rehabilitation. Sentinel 4A Diagnosis error. It Patient presented with vaginal bleeding, Policy written for ED staff over the use of Recommendations was believed patient and Misoprostol to 'complete Misoprostol. implemented. had passed products miscarriage'. Staff education undertaken. of conception. Ultrasound showed a live fetus with fetal Misoprostol given to bradycardia (slow pulse). complete miscarriage. Patient given activated charcoal within 12 minutes of being given Misoprostol. Later scan showed a non-viable pregnancy. Serious 4C Attempted suicide. Cleared for discharge with family by Risk assessment reviewed with staff. New ED department Mental Health team. opened in March 2011. Keys given so staff can readily access Requested to go to the toilet, and found toilets in emergencies. cyanosed and unconsciousness. New department and procedures Emergency action taken. reduces risk. Difficulty monitoring mental health patients in previous department.
Serious 4B Inappropriate procedure performed. Abdominal ascites tap performed despite ultrasound stating no free fluid present. Deteriorated overnight with increasing abdominal pain and hypotension from wall haematoma. ICU admission. Discharged after rehabilitation. Review of rationale with doctor. Reinforce communication with senior consultant. Sentinel 4A Diagnosis error. It was believed patient had passed products of conception. Misoprostol given to complete miscarriage. Patient presented with vaginal bleeding, and Misoprostol to 'complete miscarriage'. Ultrasound showed a live fetus with fetal bradycardia (slow pulse). Patient given activated charcoal within 12 minutes of being given Misoprostol. Later scan showed a non-viable pregnancy. Policy written for ED staff over the use of Misoprostol. Staff education undertaken. Recommendations implemented. Serious 4C Attempted suicide. Cleared for discharge with family by Mental Health team. Requested to go to the toilet, and found cyanosed and unconsciousness. Emergency action taken. Difficulty monitoring mental health patients in previous department. Risk assessment reviewed with staff. Keys given so staff can readily access toilets in emergencies. New department and procedures reduces risk. New ED department opened in March 2011.
SSE-cases-2010-11-FINALv1.docx