Bay District Health Board www.hawkesbay.health.nz Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code Sentinel 6 Fall resulting in Falls risk assessment completed In-service education to include falls Hospital project expanded fractured hip. Patient and falls prevention strategies minimisation. scope of responsibility for falls died three days post incorporated into care plan. minimisation to be fall. Staff member left patient unsupported for a short period of time. Sentinel 6 Fall resulting in Falls risk assessment completed No recommendations. fractured hip and arm and falls prevention strategies and head injury. incorporated into care plan. Patient died 23 days Fall result of impulsive behaviour. post fall. Aspiration pneumonia a contributing factor to death. Sentinel 4A Failure to identify Failure to recognise deteriorating Fetal monitoring training for staff. Education completed. maternal and fetal condition. Review clinical responsibility between Policies and procedures deterioration during Miscommunication between independent midwife and hospital reviewed, including labour. independent midwife and medical team. communication methods. Infant died several staff. Review methods of communication Awaiting Coroner’s findings. hours after birth. with patients and between clinical staff. Referred to the Coroner. Serious 4G Delayed diagnosis due Patient waiting greater than Review management of endoscopy Full clinical and administration to failure to schedule expected time for colonoscopy. waiting list systems and processes. review of waiting list appointment within completed. Patient postponed for more urgent required timeframe. case. Access criteria developed. Resources reviewed. Waiting times improved.
Bay District Health Board www.hawkesbay.health.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Sentinel 6 Fall resulting in fractured hip. Patient died three days post fall. Falls risk assessment completed and falls prevention strategies incorporated into care plan. Staff member left patient unsupported for a short period of time. In-service education to include falls minimisation. Hospital project expanded scope of responsibility for falls minimisation to be Sentinel 6 Fall resulting in fractured hip and arm and head injury. Patient died 23 days post fall. Falls risk assessment completed and falls prevention strategies incorporated into care plan. Fall result of impulsive behaviour. Aspiration pneumonia a contributing factor to death. No recommendations. Sentinel 4A Failure to identify maternal and fetal deterioration during labour. Infant died several hours after birth. Failure to recognise deteriorating condition. Miscommunication between independent midwife and medical staff. Fetal monitoring training for staff. Review clinical responsibility between independent midwife and hospital team. Review methods of communication with patients and between clinical staff. Referred to the Coroner. Education completed. Policies and procedures reviewed, including communication methods. Awaiting Coroner’s findings. Serious 4G Delayed diagnosis due to failure to schedule appointment within required timeframe. Patient waiting greater than expected time for colonoscopy. Patient postponed for more urgent case. Review management of endoscopy waiting list systems and processes. Full clinical and administration review of waiting list completed. Access criteria developed. Resources reviewed. Waiting times improved.
SSE_cases_2010_11_FINALv1.docx