Counties Manukau District Health www.cmdhb.org.nz Serious or Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 1 CT scan performed on Name label mistakenly attached Review process of storing patient A Patient Identification patient in error. to another patient’s CT request identification labels and develop has been established to review form. interventions to improve safety of incidents involving system. misidentification of patients. Investigate the potential for This group is currently working electronic requests for procedures. on better systems for storing and managing labels. An electronic solution is not currently feasible, but is likely to be developed in the next 24 months. The group is investigating ways of modifying internal referral processes for procedures. Serious 1 Gastroscopy procedure Name label mistakenly attached Review process of storing patient The Patient Identification was completed on a to another patient’s form due to: identification labels and develop is working on a better system patient when meant for interventions to improve safety of for storing and managing practice of storing patient another patient. The system. labels. identification labels for multiple patient then required a patients in a single location Develop and implement a A modified World Health second procedure to Gastroenterology Procedural Checklist. Organization (WHO) Time Out reinsert a stomach tube process of writing most procedures checklist has been (nasojejeunal tube) referrals at the end of the ward Develop standard operating procedures implemented in Endoscopy. resulting in a gastric round for Gastroenterology Intervention Suite. perforation. An Endoscopy Quality Group absence of a clearly defined has been established to process, defined roles, use of develop standard operating Out’ in establishing patient ‘Time procedures. identity.
Counties Manukau District Health www.cmdhb.org.nz Serious or sentinel code Description of event Review findings Recommendations/actions Follow-up Serious 1 CT scan performed on patient in error. Name label mistakenly attached to another patient’s CT request form. Review process of storing patient identification labels and develop interventions to improve safety of system. Investigate the potential for electronic requests for procedures. A Patient Identification has been established to review incidents involving misidentification of patients. This group is currently working on better systems for storing and managing labels. An electronic solution is not currently feasible, but is likely to be developed in the next 24 months. The group is investigating ways of modifying internal referral processes for procedures. Serious 1 Gastroscopy procedure was completed on a patient when meant for another patient. The patient then required a second procedure to reinsert a stomach tube (nasojejeunal tube) resulting in a gastric perforation. Name label mistakenly attached to another patient’s form due to: practice of storing patient identification labels for multiple patients in a single location process of writing most referrals at the end of the ward round absence of a clearly defined process, defined roles, use of ‘Time Out’ in establishing patient identity. Review process of storing patient identification labels and develop interventions to improve safety of system. Develop and implement a Gastroenterology Procedural Checklist. Develop standard operating procedures for Gastroenterology Intervention Suite. The Patient Identification is working on a better system for storing and managing labels. A modified World Health Organization (WHO) Time Out procedures checklist has been implemented in Endoscopy. An Endoscopy Quality Group has been established to develop standard operating procedures.
SSE_cases_2010_11_FINALv1.docx