Serious 4B Treatment delayed in a Nursing staff did not recognise Education and training regarding Training package around patient with a severe changes associated with patients who may have this pathology. assessing neurological status stroke who deteriorated deterioration in a patient with a using the GCS has been Institute regular formal competency and subsequently died. severe stroke and did not developed. This includes an assessments for all nursing staff within document observations to be completed prior the stroke ward to ensure maintenance overnight. It is unlikely this would to a face-to-face competency of clinical skills with regard to using the have changed the outcome for assessment. Glasgow Coma Scale (GCS) to assess this patient. neurological status. This training will be Variations in staff understanding implemented on the ward and about when and how often also included in an neurological observations should organisation-wide orientation be undertaken in the package. neurologically compromised patient, including triggers for action. Serious 4B After surgery, a patient There was no mechanism in Develop a standardised discharge A standardised discharge was not discharged on a place to ensure all discharge checklist and pilot in Surgical Services checklist was developed and blood thinner (Enoxaparin) instructions are completed with a view to possible roll-out across piloted in Surgical Services. A as planned, and was and/or checked off prior to the the organisation. working group is being readmitted with a blood patients discharge. developed to consider possible Review the organisational process of clot (pulmonary saddle roll-out across the division and Enoxaparin dispensing Enoxaparin and develop an embolism). No permanent then the organisation. prescriptions are not included on organisation-wide flow harm. the discharge medications A review of the organisational prescription as it is customary process for dispensing practice to dispense from the Enoxaparin was completed. patient’s ward. Flow charts and posters were developed and placed in all medication areas. The pharmacy website was updated with new information.
Serious 4B Treatment delayed in a patient with a severe stroke who deteriorated and subsequently died. Nursing staff did not recognise changes associated with deterioration in a patient with a severe stroke and did not document observations overnight. It is unlikely this would have changed the outcome for this patient. Variations in staff understanding about when and how often neurological observations should be undertaken in the neurologically compromised patient, including triggers for action. Education and training regarding patients who may have this pathology. Institute regular formal competency assessments for all nursing staff within the stroke ward to ensure maintenance of clinical skills with regard to using the Glasgow Coma Scale (GCS) to assess neurological status. Training package around assessing neurological status using the GCS has been developed. This includes an to be completed prior to a face-to-face competency assessment. This training will be implemented on the ward and also included in an organisation-wide orientation package. Serious 4B After surgery, a patient was not discharged on a blood thinner (Enoxaparin) as planned, and was readmitted with a blood clot (pulmonary saddle embolism). No permanent harm. There was no mechanism in place to ensure all discharge instructions are completed and/or checked off prior to the patients discharge. Enoxaparin prescriptions are not included on the discharge medications prescription as it is customary practice to dispense from the patient’s ward. Develop a standardised discharge checklist and pilot in Surgical Services with a view to possible roll-out across the organisation. Review the organisational process of dispensing Enoxaparin and develop an organisation-wide flow A standardised discharge checklist was developed and piloted in Surgical Services. A working group is being developed to consider possible roll-out across the division and then the organisation. A review of the organisational process for dispensing Enoxaparin was completed. Flow charts and posters were developed and placed in all medication areas. The pharmacy website was updated with new information.
SSE-cases-2010-11-FINALv1.docx