Canterbury District Health Board www.scdhb.health.nz Serious or Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 5 Patient prescribed Correct medication reconciliation Standardisation of process and Action plan developed incorrect medications process was not followed. confirmation requirements for and monitored. All resulting in a medication reconciliation with action points significant community and hospital pharmacists progressing with deterioration in established. planned roll-out of patient’s physical medicines condition. The patient reconciliation across all made a full recovery. inpatient services in 2011. Serious 6 Resident fall in Independently mobile resident hospital dementia sustained a fractured hip. unit, resulting in Fracture surgically repaired. fractured hip. Serious 6 Patient fall with no Falls risk assessment completed obvious injury until and fall prevention plan in place. two days later when swelling and X-ray revealed a fractured leg (tibial plateau). Serious 6 Patient fall resulting in Falls risk assessment completed serious wound to leg. on admission and falls prevention plan in place, including requirement for supervision when mobilising. Patient attempted to mobilise independently.
Canterbury District Health Board www.scdhb.health.nz Serious or sentinel code Description of event Review findings Recommendations/actions Follow-up Serious 5 Patient prescribed incorrect medications resulting in a significant deterioration in patient’s physical condition. The patient made a full recovery. Correct medication reconciliation process was not followed. Standardisation of process and confirmation requirements for medication reconciliation with community and hospital pharmacists established. Action plan developed and monitored. All action points progressing with planned roll-out of medicines reconciliation across all inpatient services in 2011. Serious 6 Resident fall in hospital dementia unit, resulting in fractured hip. Independently mobile resident sustained a fractured hip. Fracture surgically repaired. Serious 6 Patient fall with no obvious injury until two days later when swelling and X-ray revealed a fractured leg (tibial plateau). Falls risk assessment completed and fall prevention plan in place. Serious 6 Patient fall resulting in serious wound to leg. Falls risk assessment completed on admission and falls prevention plan in place, including requirement for supervision when mobilising. Patient attempted to mobilise independently.
SSE_cases_2010_11_FINALv1.docx