Sentinel 4D Aspiration of feed into Nasogastric feeding uncommon on this Increase awareness in nursing staff Completed. lungs due to ward. around best practise with naso-gastric dislodgement of feeding. Partial tube removal by patient not naso-gastric tube. identified. Commencement of bedside handovers. Patient died despite Naso-gastric Resource Nurse appointed. appropriate treatment. Serious 6 Fall causing fractured Unobserved fall out of bed. in place. upper arm and intracranial (brain) bleeding. Serious 6 Fall causing fractured Fell returning from toilet. Severe ribs and minor underlying medical conditions. Death internal bleeding. unrelated to injuries. Serious 6 Fall causing fractured Child fell in play area of Children’s tooth. Emergency Department. Serious 6 Fall causing facial Unobserved fall from bed with rails while fracture and awaiting X-ray. intracranial (brain) bleeding. Serious 6 Fall causing fractured Unwitnessed fall when going to toilet. upper arm. Serious 6 Fall causing spinal Confused patient left ward and fell fractures. outside hospital. Serious 6 Fall causing fractured Confused. Fell while mobilising without hip. assistance. Serious 6 Fall causing scalp Dementia. Fell while mobilising without laceration. assistance.
Sentinel 4D Aspiration of feed into lungs due to dislodgement of naso-gastric tube. Patient died despite appropriate treatment. Nasogastric feeding uncommon on this ward. Partial tube removal by patient not identified. Increase awareness in nursing staff around best practise with naso-gastric feeding. Commencement of bedside handovers. Naso-gastric Resource Nurse appointed. Completed. Serious 6 Fall causing fractured upper arm and intracranial (brain) bleeding. Unobserved fall out of bed. in place. Serious 6 Fall causing fractured ribs and minor internal bleeding. Fell returning from toilet. Severe underlying medical conditions. Death unrelated to injuries. Serious 6 Fall causing fractured tooth. Child fell in play area of Children’s Emergency Department. Serious 6 Fall causing facial fracture and intracranial (brain) bleeding. Unobserved fall from bed with rails while awaiting X-ray. Serious 6 Fall causing fractured upper arm. Unwitnessed fall when going to toilet. Serious 6 Fall causing spinal fractures. Confused patient left ward and fell outside hospital. Serious 6 Fall causing fractured hip. Confused. Fell while mobilising without assistance. Serious 6 Fall causing scalp laceration. Dementia. Fell while mobilising without assistance.
SSE_cases_2010_11_FINALv1.docx