Serious 4D Perforation of uterus Surgical technique used (Microwave Scheduled for surgical audit. Awaiting review. during gynaecological endometrial ablation technique) caused surgery with full thickness uterine burn. injury requiring further surgery (rectal resection, hysterectomy and temporary ileostomy). Serious Child flown from Future booking for CT scan had not been Modification of booking system to require Organisation-wide 1 – another DHB for an cancelled urgent surgery had been review and re-confirmation of future under review. unnecessary CT scan required, making the scan unnecessary. outpatient bookings after inpatient under general admissions. anaesthesia. Serious 4D Injury to upper lobe of Misinterpretation of intra-operative test Surgical Complete lung during surgery Reduced visualisation from Re-confirmed the need for absolute (resection of lower surgical approach certainty of anatomy to division of lobe), eventually major structures. requiring complete removal of left lung. Sentinel 4B Four-month delay in Surgical audit form completed without Reinforce standards with surgical Completed. treatment for cancer histology available. registrars. In process with regional IT as clinical staff No system to ensure histology results Mandatory electronic escalation system provider and individual unaware of are reviewed after patient discharge. for unsigned reports. services. unexpected findings on histology report. No mandatory escalation process for Retrospective sign-off process for all In process. unreviewed histology reports. unaccepted histology reports automatic – 2009 or earlier, manual 2010 onwards. Important unanticipated abnormal histology results not highlighted. Reduce/eliminate reports. May incorporate into e-Lab Review reporting systems with pathology development. and information systems.
Serious 4D Perforation of uterus during gynaecological surgery with injury requiring further surgery (rectal resection, hysterectomy and temporary ileostomy). Surgical technique used (Microwave endometrial ablation technique) caused full thickness uterine burn. Scheduled for surgical audit. Awaiting review. Serious 1 Child flown from another DHB for an unnecessary CT scan under general anaesthesia. Future booking for CT scan had not been cancelled urgent surgery had been required, making the scan unnecessary. Modification of booking system to require review and re-confirmation of future outpatient bookings after inpatient admissions. Organisation-wide – under review. Serious 4D Injury to upper lobe of lung during surgery (resection of lower lobe), eventually requiring complete removal of left lung. Misinterpretation of intra-operative test Reduced visualisation from surgical approach Surgical Re-confirmed the need for absolute certainty of anatomy to division of major structures. Complete Sentinel 4B Four-month delay in treatment for cancer as clinical staff unaware of unexpected findings on histology report. Surgical audit form completed without histology available. No system to ensure histology results are reviewed after patient discharge. No mandatory escalation process for unreviewed histology reports. Important unanticipated abnormal histology results not highlighted. Reinforce standards with surgical registrars. Mandatory electronic escalation system for unsigned reports. Retrospective sign-off process for all unaccepted histology reports – automatic 2009 or earlier, manual 2010 onwards. Reduce/eliminate reports. Review reporting systems with pathology and information systems. Completed. In process with regional IT provider and individual services. In process. May incorporate into e-Lab development.
SSE-cases-2010-11-FINALv1.docx