Sentinel 4A 15-month delay in X-ray taken prior to Patient’s GPs to be sent a copy of all Completed. diagnosing lung dental surgery showed a lung reports generated from the dental unit. cancer. Palliative lesion. Previous chest X-ray films/reports must treatment undertaken Patient presented to ED with be viewed when an abnormality is and patient died chest pain, lesion was larger detected. Ongoing. several months later. and had spread (metastisised). No copy of X-ray report sent to GP. Previous X-rays not reviewed. Serious 5 Medication given in Order of Theatre list was Develop a flow chart for premed options Completed. incorrect order, changed at short notice due including timeframes and patient resulting in patient to a hole in the instrument presentation. experiencing wrapping being detected. Replace sterile tray shelving units to allow temporary paralysis This resulted in the patient for better storage of sterile trays. Audit in six months for prior to procedure in not being mentally prepared compliance. theatre. Patient and it was thought there was Consider protective devices for corners of traumatised by the no time to administer a instrument trays to prevent inadvertent event. piercing of sterile packing. Anaesthetic medications Introduce red-barrelled syringes for Under way. drawn up and syringes were paralysing agents. labelled; however, incorrect Research and implement anxiety rating syringe used. scale to accurately identify patients’ Patient known to be anxious anxiety. on previous occasions and Review Pre-operative Checklist. Include this was not adequately Implement and audit in six months section for anxiety rating and responded to by staff. for compliance. notification of who the patient wishes information to be given to such as next of kin/support person. Benchmarking with other DHBs is recommended.
Sentinel 4A 15-month delay in diagnosing lung cancer. Palliative treatment undertaken and patient died several months later. X-ray taken prior to dental surgery showed a lung lesion. Patient presented to ED with chest pain, lesion was larger and had spread (metastisised). No copy of X-ray report sent to GP. Previous X-rays not reviewed. Patient’s GPs to be sent a copy of all reports generated from the dental unit. Previous chest X-ray films/reports must be viewed when an abnormality is detected. Completed. Ongoing. Serious 5 Medication given in incorrect order, resulting in patient experiencing temporary paralysis prior to procedure in theatre. Patient traumatised by the event. Order of Theatre list was changed at short notice due to a hole in the instrument wrapping being detected. This resulted in the patient not being mentally prepared and it was thought there was no time to administer a Anaesthetic medications drawn up and syringes were labelled; however, incorrect syringe used. Patient known to be anxious on previous occasions and this was not adequately responded to by staff. Develop a flow chart for premed options including timeframes and patient presentation. Replace sterile tray shelving units to allow for better storage of sterile trays. Consider protective devices for corners of instrument trays to prevent inadvertent piercing of sterile packing. Introduce red-barrelled syringes for paralysing agents. Research and implement anxiety rating scale to accurately identify patients’ anxiety. Review Pre-operative Checklist. Include section for anxiety rating and notification of who the patient wishes information to be given to such as next of kin/support person. Benchmarking with other DHBs is recommended. Completed. Audit in six months for compliance. Under way. Implement and audit in six months for compliance.
SSE-cases-2010-11-FINALv1.docx