Serious 4G Patient pulled out Critically ill, confused, patient bled to Review how critically unwell, elderly confused intravenous line, death because his femoral central patients are managed in acute settings this action – which led to venous line was pulled out. The patient included in the Delirium project. death. had a history of pulling out lines and the Review handover and transfer process whereby patient required restraint. patients transferred from areas with high nurse: Inadequate assessment of the risks for patient ratio to areas with lower nurse: patient ratio. this patient was undertaken at the Formalise the handover process between health receiving ward, and inadequate professionals as part of the Hospital at Night project. documented plan of care for the management of the patient’s confusion, Random by two Nurse/Midwife Directorate history of pulling lines and presence of a members to critically analyse a set of patient records central venous line. and provide feedback to the charge nurse where this is inadequate or incomplete. Death referred to Coroner who decided not to investigate further. Serious 4B Senior doctor The practice of not rostering specialist Changes made to roster to ensure specialty medical Completed. responsible for medical staff on the night duties resulted are on call. patient was not in consultant not being called to review informed of patient. deteriorating patient condition. Patient died later in day. Serious 4B Failure to Misinterpretation of patient’s clinical Document for management of trauma cases to be diagnose/ signs and symptoms led to patient being updated in required format. recognise clinically managed as a stable rather Implementation plan to include education and unstable patient. than an unstable patient. ongoing education and orientation. To re-assess ED medical staff number against expected norm for other equivalent EDs.
Serious 4G Patient pulled out intravenous line, which led to death. Critically ill, confused, patient bled to death because his femoral central venous line was pulled out. The patient had a history of pulling out lines and the patient required restraint. Inadequate assessment of the risks for this patient was undertaken at the receiving ward, and inadequate documented plan of care for the management of the patient’s confusion, history of pulling lines and presence of a central venous line. Death referred to Coroner who decided not to investigate further. Review how critically unwell, elderly confused patients are managed in acute settings – this action included in the Delirium project. Review handover and transfer process whereby patients transferred from areas with high nurse: patient ratio to areas with lower nurse: patient ratio. Formalise the handover process between health professionals as part of the Hospital at Night project. Random by two Nurse/Midwife Directorate members to critically analyse a set of patient records and provide feedback to the charge nurse where this is inadequate or incomplete. Serious 4B Senior doctor responsible for patient was not informed of deteriorating patient condition. Patient died later in day. The practice of not rostering specialist medical staff on the night duties resulted in consultant not being called to review patient. Changes made to roster to ensure specialty medical are on call. Completed. Serious 4B Failure to diagnose/ recognise unstable patient. Misinterpretation of patient’s clinical signs and symptoms led to patient being clinically managed as a stable rather than an unstable patient. Document for management of trauma cases to be updated in required format. Implementation plan to include education and ongoing education and orientation. To re-assess ED medical staff number against expected norm for other equivalent EDs.
SSE_cases_2010_11_FINALv1.docx