Taranaki District Health Board www.tdhb.org.nz Serious or Event Description of Review findings Recommendations/actions Follow-up sentinel code event Serious 1 Wrong patient Both father and son had exactly the same Ensure that all referrals have the patient’s NHI All anaesthetised (son name and contact details. number and date of birth clearly documented. completed rather than father, Son was registered on the local Patient Ensure that when discussing consent with the with same name). Management System with his National patient, the consent form is completed, including the Health Index (NHI) number but the father identification of the signee. was not. Ensure staff read all referrals thoroughly and not Son had symptoms that correlated with his accept/enter any referrals that are not completed father’s surgical diagnosis. appropriately. Reminders given to staff. Son had recently been returned to his Referral documents are to be reviewed at mother’s care and displayed symptoms that and anaesthetic assessment led her to believe that her son was already appointments. on the wait list. Discussion to occur between the contracted provider The surgical referral form did not contain hospital and the DHB to identify where streamlining the patient’s NHI number. can occur. The identification of the signee on the consent form (ie, patient, parent or guardian) was not marked. The procedure for adding a patient to the surgical waiting list was not followed.
Taranaki District Health Board www.tdhb.org.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 1 Wrong patient anaesthetised (son rather than father, with same name). Both father and son had exactly the same name and contact details. Son was registered on the local Patient Management System with his National Health Index (NHI) number but the father was not. Son had symptoms that correlated with his father’s surgical diagnosis. Son had recently been returned to his mother’s care and displayed symptoms that led her to believe that her son was already on the wait list. The surgical referral form did not contain the patient’s NHI number. The identification of the signee on the consent form (ie, patient, parent or guardian) was not marked. The procedure for adding a patient to the surgical waiting list was not followed. Ensure that all referrals have the patient’s NHI number and date of birth clearly documented. Ensure that when discussing consent with the patient, the consent form is completed, including the identification of the signee. Ensure staff read all referrals thoroughly and not accept/enter any referrals that are not completed appropriately. Reminders given to staff. Referral documents are to be reviewed at and anaesthetic assessment appointments. Discussion to occur between the contracted provider hospital and the DHB to identify where streamlining can occur. All completed
SSE_cases_2010_11_FINALv1.docx