Serious 4A Missed diagnosis of Headache was not usual for Policy change: Emergency medicine Implemented. bleed prior subarachnoid bleeding. specialist review required to confirm ‘sentinel’ to large brain discharge without further investigation for No diagnostic tests performed. (subarachnoid) atypical headache presentations. haemorrhage three days later. No long-term harm; high-risk event. Serious Heparin infusion Confusion between multiple pumps. Use of infusion pump software. Implemented. 5 ‘smart’ (anticoagulant) Unfamiliarity with volumetric pumps. incorrectly increased to 80ml/hr during minor surgery, causing significant bleeding. Sentinel 4A 14 months for an Booked into incorrect clinic. Central Referrals Office to code’ Completed. ‘colour urgent (<8 weeks) clinics as a means of clinic identification. Administrative procedures for incorrect appointment in the clinic attendance unclear. Written guideline for process for patients eye clinic. Patient In progress. presenting to the wrong clinic. now legally blind. Referral sent to wrong DHB twice. Regional issue to be discussed with neighbouring DHBs. In progress. Unclear 10 Delay in transferring Inadequate communication and Electronic register and tracking system In development. baby from referring handover. for referrals. DHB. Death possibly Infectious status conflict with clinical Referrers advised of thresholds for preventable by earlier In progress. urgency. escalation. transfer. No change required. Review infection control guidelines.
Serious 4A Missed diagnosis of ‘sentinel’ bleed prior to large brain (subarachnoid) haemorrhage three days later. No long-term harm; high-risk event. Headache was not usual for subarachnoid bleeding. No diagnostic tests performed. Policy change: Emergency medicine specialist review required to confirm discharge without further investigation for atypical headache presentations. Implemented. Serious 5 Heparin infusion (anticoagulant) incorrectly increased to 80ml/hr during minor surgery, causing significant bleeding. Confusion between multiple pumps. Unfamiliarity with volumetric pumps. Use of infusion pump ‘smart’ software. Implemented. Sentinel 4A 14 months for an urgent (<8 weeks) appointment in the eye clinic. Patient now legally blind. Booked into incorrect clinic. Administrative procedures for incorrect clinic attendance unclear. Referral sent to wrong DHB twice. Central Referrals Office to ‘colour code’ clinics as a means of clinic identification. Written guideline for process for patients presenting to the wrong clinic. Regional issue to be discussed with neighbouring DHBs. Completed. In progress. In progress. Unclear 10 Delay in transferring baby from referring DHB. Death possibly preventable by earlier transfer. Inadequate communication and handover. Infectious status conflict with clinical urgency. Electronic register and tracking system for referrals. Referrers advised of thresholds for escalation. Review infection control guidelines. In development. In progress. No change required.
SSE_cases_2010_11_FINALv1.docx