Northland District Health Board Serious or Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 5 Patient Omission of patient identification checks Revisit medication safety and All undertaken. misidentification during medication administration. administration of high-risk trial for all resulted in wrong Emergency Department (ED) staff. workload management and patient receiving Review relevance to ED environment. processes inadequate. medication. Review model of care. Handover processes did not provide relevant information clearly. Formalise handover use – (Situation, Background, Assessment, Recommendation, Response) tool. Revise overload code plan to include staff workload management. Sentinel 4 B&C Unexpected at Inadequate communication occurred SBARR Situation, Background, Handover is structured by – home. Unclear between the health professionals Assessment, Recommendation, using standard communication involved in the care pathway; this had Response (or equivalent) utilised to documentation on delivery – between ambulance the potential to impact on the overall convey handover information. suite. officers and hospital outcome. Single set of clinical notes. Protocols are easy to staff, baby requiring Inadequate documentation. access, both electronically unanticipated Consider opportunities for multiagency and in hard copy. admission to intensive neonatal resuscitation education. care unit. Flow chart developed for the ED ambulance call record to use with the ambulance meet the need of the maternity services. radio. Reinforce the use of the emergency call Monthly Basic Life Support system in hospital to seek any updates including emergency assistance. emergency call processes.
Northland District Health Board Serious or sentinel code Description of event Review findings Recommendations/actions Follow-up Serious 5 Patient misidentification resulted in wrong patient receiving medication. Omission of patient identification checks during medication administration. workload management and processes inadequate. Handover processes did not provide relevant information clearly. Revisit medication safety and administration of high-risk for all Emergency Department (ED) staff. Review relevance to ED environment. Review model of care. Formalise handover – use (Situation, Background, Assessment, Recommendation, Response) tool. Revise overload code plan to include staff workload management. All undertaken. Sentinel 4 B&C Unexpected at home. Unclear communication between ambulance officers and hospital staff, baby requiring unanticipated admission to intensive care unit. Inadequate communication occurred between the health professionals involved in the care pathway; this had the potential to impact on the overall outcome. Inadequate documentation. SBARR – Situation, Background, Assessment, Recommendation, Response – (or equivalent) utilised to convey handover information. Single set of clinical notes. Consider opportunities for multiagency neonatal resuscitation education. the ED ambulance call record to meet the need of the maternity services. Reinforce the use of the emergency call system in hospital to seek any emergency assistance. Handover is structured by using standard documentation on delivery suite. Protocols are easy to access, both electronically and in hard copy. Flow chart developed for use with the ambulance radio. Monthly Basic Life Support updates including emergency call processes. trial
SSE_cases_2010_11_FINALv1.docx