Waitemata District Health Board Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 4D Blood cross-matched Emergency situation at change of shift Processes reviewed: Recommendations/ for mother (diagnosis with multiple teams, resulting in corrective actions requesting blood for a baby of placental inadequate checking process. implemented. abruption) was given emergency call in theatre No adverse harm to baby. to baby in error. cord gas in resuscitation situation. Serious 4D Patient discharged Patient had repeated bleeding with low Education around ordering ultrasound for Completed. with retained products haemoglobin level of 71. retained products if there is repeated (placenta) after birth. bleeding. Readmitted with persistent bleeding and No ultrasound was plan for further surgery. conducted prior to discharge. Experienced a cardiac arrest in operating theatre. Patient fully recovered. Sentinel 4A Patient was CTG was misread by independent All CTGs to be reviewed by a clinical discharged in early midwife. charge midwife (CCM) or a senior labour when medical officer (SMO). Midwife called and was told that no cardiotocograph movements noted since woman had (CTG) was misread. gone home. (Discharge was 11.28am, readmission at 6pm.) Reassessment and fetal death confirmed.
Waitemata District Health Board Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4D Blood cross-matched for mother (diagnosis of placental abruption) was given to baby in error. Emergency situation at change of shift with multiple teams, resulting in inadequate checking process. No adverse harm to baby. Processes reviewed: requesting blood for a baby emergency call in theatre cord gas in resuscitation situation. Recommendations/ corrective actions implemented. Serious 4D Patient discharged with retained products (placenta) after birth. No ultrasound was conducted prior to discharge. Patient had repeated bleeding with low haemoglobin level of 71. Readmitted with persistent bleeding and plan for further surgery. Experienced a cardiac arrest in operating theatre. Patient fully recovered. Education around ordering ultrasound for retained products if there is repeated bleeding. Completed. Sentinel 4A Patient was discharged in early labour when cardiotocograph (CTG) was misread. CTG was misread by independent midwife. Midwife called and was told that no movements noted since woman had gone home. (Discharge was 11.28am, readmission at 6pm.) Reassessment and fetal death confirmed. All CTGs to be reviewed by a clinical charge midwife (CCM) or a senior medical officer (SMO).
SSE_cases_2010_11_FINALv1.docx