Serious 5 Excessive sedative Poor communication between ward and Paediatric sedation policy to be reviewed Completed dose for an infant radiology regarding use of sedation. and updated. undergoing a Development of a checklist for the wards. radiology procedure, In progress causing coma for 24 Handover guidelines between wards and In progress hours. Radiology staff. Serious 5 Infant received 10 Incorrect prescription not detected. New design paediatric fluid prescription In final stage of overdose of and administration chart. development. Chart does not highlight bolus volume intravenous fluids. size. Required additional No limit for volume on infusion pump. Use of infusion pump software. Implemented. treatment but no adverse effects. Serious 4D Three-month delay in Overdue procedure not identified. Alert system in radiology information Not possible with current liver biopsy system (RIS) for overdue prioritisation system. No clinical review prior to procedure. performed without requests. review of No IV access constrained treatment Escalation process for review of elective appropriateness when bleeding occurred. Ongoing. procedures when patient condition has when patient unwell changed. and at high risk. Standardise practice: all patients having Implemented. Post-procedure major solid organ cutting needle bleeding. biopsy to have IV access. Sentinel 4A Delayed diagnosis of Treatment was focused on the lower leg Revise district nursing supervision Implemented. major pressure area ulcers. Revision of assessment form to be more of a patient under Complex patient, no multi-disciplinary comprehensive including district nursing care in or long-term holistic care plan. information. the community. Identification of all complex patients and Subsequently died assignment of primary nurse. from severe infection.
Serious 5 Excessive sedative dose for an infant undergoing a radiology procedure, causing coma for 24 hours. Poor communication between ward and radiology regarding use of sedation. Paediatric sedation policy to be reviewed and updated. Development of a checklist for the wards. Handover guidelines between wards and Radiology staff. Completed In progress In progress Serious 5 Infant received 10 overdose of intravenous fluids. Required additional treatment but no adverse effects. Incorrect prescription not detected. Chart does not highlight bolus volume size. No limit for volume on infusion pump. New design paediatric fluid prescription and administration chart. Use of infusion pump software. In final stage of development. Implemented. Serious 4D Three-month delay in liver biopsy performed without review of appropriateness when patient unwell and at high risk. Post-procedure major bleeding. Overdue procedure not identified. No clinical review prior to procedure. No IV access constrained treatment when bleeding occurred. Alert system in radiology information system (RIS) for overdue prioritisation requests. Escalation process for review of elective procedures when patient condition has changed. Standardise practice: all patients having solid organ cutting needle biopsy to have IV access. Not possible with current system. Ongoing. Implemented. Sentinel 4A Delayed diagnosis of major pressure area of a patient under district nursing care in the community. Subsequently died from severe infection. Treatment was focused on the lower leg ulcers. Complex patient, no multi-disciplinary or long-term holistic care plan. Revise district nursing supervision Revision of assessment form to be more comprehensive including information. Identification of all complex patients and assignment of primary nurse. Implemented.
SSE-cases-2010-11-FINALv1.docx