Serious 6 Patient fell from beside Palliative care patient Patient was placed on constant bed, resulting in hip assessed as a very high supervision. fracture. risk. All appropriate falls risk All made aware of the Whanganui minimisation measures Completed. Centre for Patient DHB’s Open Disclosure policy and timely instituted, including bell mat Safety will monitor compliance communication with families. alarm. Alarm sounded, staff with the Open Disclosure policy. responded immediately but patient had already fallen. There was a delay in informing the family of the event. Serious 4 A Delay in responding to Junior medical did not Tutorial held for junior medical staff to Completed. deteriorating patient escalate their concerns to improve communication competency. post-operatively. senior medical staff. The surgical team have conducted Patient required further Completed. Nursing did not follow of the acute ‘recognition extensive bowel the early warning score abdomen’. surgery and transfer to protocol and notify the Duty a tertiary facility Requirements of Health Records Policy Audit six-monthly. Nurse Manager about the Intensive Care Unit. and documentation standards reiterated patient’s condition. to all Once the deterioration was recognised the patient’s vital signs were closely monitored; however, not all recordings were documented.
Serious 6 Patient fell from beside bed, resulting in hip fracture. Palliative care patient assessed as a very high risk. All appropriate falls risk minimisation measures instituted, including bell mat alarm. Alarm sounded, staff responded immediately but patient had already fallen. There was a delay in informing the family of the event. Patient was placed on constant supervision. All made aware of the Whanganui DHB’s Open Disclosure policy and timely communication with families. Completed. Centre for Patient Safety will monitor compliance with the Open Disclosure policy. Serious 4 A Delay in responding to deteriorating patient post-operatively. Patient required further extensive bowel surgery and transfer to a tertiary facility Intensive Care Unit. Junior medical did not escalate their concerns to senior medical staff. Nursing did not follow the early warning score protocol and notify the Duty Nurse Manager about the patient’s condition. Once the deterioration was recognised the patient’s vital signs were closely monitored; however, not all recordings were documented. Tutorial held for junior medical staff to improve communication competency. The surgical team have conducted ‘recognition of the acute abdomen’. Requirements of Health Records Policy and documentation standards reiterated to all Completed. Completed. Audit six-monthly.
SSE_cases_2010_11_FINALv1.docx