Nelson Marlborough District Health Board www.nmdhb.govt.nz Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 4B A 42-week gestation Avoidable upper airway obstruction. Review the discharge and transfer process between infant developed the recovery area and postnatal ward. breathing difficulties Ensure that orderlies are utilised for transporting the during transfer to the patient during transfer enabling the escorting postnatal ward. midwife to care as required in line with NMDHB policy for internal transfer of patients. Review of postpartum care following delivery to afford continuity of midwifery care to mothers and infants. District-wide policy review to provide guidance for midwives regarding appropriate supervision of mother and infant whilst breastfeeding during transfer, especially if mother affected by sedative medication. Review the appropriateness of the number and placement of resuscitaires and consider the need for permanent placement in theatre/recovery area. Serious 6 Patient sustained The patient’s fall was an unforeseeable Nil. bilateral wrist fractures incident. Appropriate assessment and as a result of a fall on intervention occurred specific to the an inpatient unit. The patient’s mobility needs. patient died several days later of an unrelated cause.
Nelson Marlborough District Health Board www.nmdhb.govt.nz Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4B A 42-week gestation infant developed breathing difficulties during transfer to the postnatal ward. Avoidable upper airway obstruction. Review the discharge and transfer process between the recovery area and postnatal ward. Ensure that orderlies are utilised for transporting the patient during transfer enabling the escorting midwife to care as required in line with NMDHB policy for internal transfer of patients. Review of postpartum care following delivery to afford continuity of midwifery care to mothers and infants. District-wide policy review to provide guidance for midwives regarding appropriate supervision of mother and infant whilst breastfeeding during transfer, especially if mother affected by sedative medication. Review the appropriateness of the number and placement of resuscitaires and consider the need for permanent placement in theatre/recovery area. Serious 6 Patient sustained bilateral wrist fractures as a result of a fall on an inpatient unit. The patient died several days later of an unrelated cause. The patient’s fall was an unforeseeable incident. Appropriate assessment and intervention occurred specific to the patient’s mobility needs. Nil.
SSE-cases-2010-11-FINALv1.docx