Waikato District Health Board Serious or Event Description of Review findings Recommendations/actions Follow-up sentinel code event Serious 4B Delay in treatment Consultant-to-consultant referrals from Discussion to at clinical directors’ forum Inter-hospital due to transport all provincial hospital when needing to regarding consultant-to-consultant referral as this in project in problems activate a transport team. not a one-business-unit issue. When criteria agreed a progress. transporting memo to come out of Chief Medical Advisor (CMA) There is no 24-hour seven-day a week patient from office to all provincial hospitals (not Waikato DHB onsite CT service. regional hospital. rural facilities), advising of new requirement. There is currently no centrally Undertake a retrospective audit of time of referral and transfer role for inter-hospital time of actual scan for after-hours patients (after transfers. 4pm) (approx 50 cases over a three-month period). There is no central air transport service, Presentation of that data to Management Executive no contractual requirements re air Committee and action plan to be developed to service, no central co-ordination, no address any issues identified. budget; plane/helicopter providers are responsible for their own maintenance. Implement the inter-hospital transfer project. This is a rare/complex clinical condition. No action plan developed as this is a national There is no clear documented pathway This risk to be added to the organisation risk within Waikato DHB of how patients with register/plan. this condition in a non trauma situation are managed. needs to be a standard approach to how patients with this condition are managed.
Waikato District Health Board Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4B Delay in treatment due to transport problems transporting patient from regional hospital. Consultant-to-consultant referrals from all provincial hospital when needing to activate a transport team. There is no 24-hour seven-day a week onsite CT service. There is currently no centrally transfer role for inter-hospital transfers. There is no central air transport service, no contractual requirements re air service, no central co-ordination, no budget; plane/helicopter providers are responsible for their own maintenance. This is a rare/complex clinical condition. There is no clear documented pathway within Waikato DHB of how patients with this condition in a non trauma situation are managed. Discussion to at clinical directors’ forum regarding consultant-to-consultant referral as this in not a one-business-unit issue. When criteria agreed a memo to come out of Chief Medical Advisor (CMA) office to all provincial hospitals (not Waikato DHB rural facilities), advising of new requirement. Undertake a retrospective audit of time of referral and time of actual scan for after-hours patients (after 4pm) (approx 50 cases over a three-month period). Presentation of that data to Management Executive Committee and action plan to be developed to address any issues identified. Implement the inter-hospital transfer project. No action plan developed as this is a national This risk to be added to the organisation risk register/plan. needs to be a standard approach to how patients with this condition are managed. Inter-hospital project in progress.
SSE_cases_2010_11_FINALv1.docx