Capital & Coast District Health Board www.ccdhb.org.nz From 1 July 2009, Capital and Coast DHB stopped using the terminology and and adopted Severity Assessment Code (SAC) rating terminology in ‘serious’ ‘sentinel’ accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with and events. “Sentinel” “Serious” Serious Event Description of Review findings Recommendations/actions Follow-up or code sentinel Serious 11 Patient self-harm. Police The review concluded that The review did not make any Not applicable. Closed. involved in response. appropriate actions and recommendations. decisions were made in respect of the management of the patient. Serious 4B Child seen twice on Review found that care Review recommended the hospital Referred to Coroner at time of same day at hospital provided by the hospital clinic clinic protocol be amended to specify event. Coroner decision not to clinic. Transferred to was appropriate. Review that antibiotics be given in the clinic to open an inquiry. Coroner hospital emergency identified a delay in the any patient suspected to be suffering reconsidering need for inquiry at department on second administration of antibiotics from meningococcal septicaemia. request of family. presentation. Patient due to the transfer time from Review also recommended that the The Paediatric Service and died in Intensive Care the clinic to the emergency DHB apologise to the family for the hospital clinic have revised the Unit later that day. department. delay in administration of antibiotics. protocol for antibiotic Meningococcal administration. Report and septicaemia. apology provided to family. Serious 4B Significant deterioration Review found that while overall Review recommended an education The education plan and the of existing pressure area care was appropriate and the plan to develop further on process for management of during hospital pressure area was at high risk pressure area management and complex wounds were developed admission. of deterioration, some aspects wound expertise, the development of a and implemented and of communication of wound process for management of complex communication processes care assessment and wounds and strengthening of between inpatient and community management were not communication between inpatient nurses strengthened. Closed. consistent and not escalated areas and community nurses. when indicated.
Capital & Coast District Health Board www.ccdhb.org.nz From 1 July 2009, Capital and Coast DHB stopped using the terminology ‘serious’ and ‘sentinel’ and adopted Severity Assessment Code (SAC) rating terminology in accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with “Sentinel” and “Serious” events. Serious or sentinel Event code Description of Review findings Recommendations/actions Follow-up Serious 11 Patient self-harm. Police involved in response. The review concluded that appropriate actions and decisions were made in respect of the management of the patient. The review did not make any recommendations. Not applicable. Closed. Serious 4B Child seen twice on same day at hospital clinic. Transferred to hospital emergency department on second presentation. Patient died in Intensive Care Unit later that day. Meningococcal septicaemia. Review found that care provided by the hospital clinic was appropriate. Review identified a delay in the administration of antibiotics due to the transfer time from the clinic to the emergency department. Review recommended the hospital clinic protocol be amended to specify that antibiotics be given in the clinic to any patient suspected to be suffering from meningococcal septicaemia. Review also recommended that the DHB apologise to the family for the delay in administration of antibiotics. Referred to Coroner at time of event. Coroner decision not to open an inquiry. Coroner reconsidering need for inquiry at request of family. The Paediatric Service and hospital clinic have revised the protocol for antibiotic administration. Report and apology provided to family. Serious 4B Significant deterioration of existing pressure area during hospital admission. Review found that while overall care was appropriate and the pressure area was at high risk of deterioration, some aspects of communication of wound care assessment and management were not consistent and not escalated when indicated. Review recommended an education plan to develop further on pressure area management and wound expertise, the development of a process for management of complex wounds and strengthening of communication between inpatient areas and community nurses. The education plan and the process for management of complex wounds were developed and implemented and communication processes between inpatient and community nurses strengthened. Closed.
SSE-cases-2010-11-FINALv1.docx