Auckland District Health Board Auckland DHB advised subsequent to publication of the 2010/11 Serious and Sentinel Event Report that two cases initially reported to the Commission as SSEs had been reviewed, and were reclassified as not being serious or sentinel events. Serious or Event Description of event Review findings Recommendations/actions Follow-up sentinel code Serious 4G Child under current Communication difficulties with Multidisciplinary risk’ discharge Ongoing. ‘at care of DHB Early Youth and Family Services (CYFS); risk planning and template. Childhood team not escalated. Improve process for escalation if plan not admitted with followed. injury. Communication standards for CYFS. Serious 1 Patient was Platelets sent to the wrong destination. Staff education regarding patient Ongoing. administered a identification standards. Checking process prior to administration platelet transfusion was inadequate. Simplify documentation and move to intended for a Implementation electronic ordering of all blood and blood different patient. No commenced. products. harm, high-risk event. Complete. Review blood bank layout and check process. Serious 5 Epidural infusion of Although colour-coded, epidural and IV Assess potential for introducing In progress. anaesthetic connections are inter-changeable. locking system. administered Credentialing/training of inconsistent. intravenously to a In progress. Revise policy and training to require woman in labour. Double of correct connection not bedside double-checking of the infusion required. No patient harm, and connection. high-risk event.
Auckland District Health Board Auckland DHB advised subsequent to publication of the 2010/11 Serious and Sentinel Event Report that two cases initially reported to the Commission as SSEs had been reviewed, and were reclassified as not being serious or sentinel events. Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 4G Child under current care of DHB Early Childhood team admitted with injury. Communication difficulties with Youth and Family Services (CYFS); risk not escalated. Multidisciplinary ‘at risk’ discharge planning and template. Improve process for escalation if plan not followed. Communication standards for CYFS. Ongoing. Serious 1 Patient was administered a platelet transfusion intended for a different patient. No harm, high-risk event. Platelets sent to the wrong destination. Checking process prior to administration was inadequate. Staff education regarding patient identification standards. Simplify documentation and move to electronic ordering of all blood and blood products. Review blood bank layout and check process. Ongoing. Implementation commenced. Complete. Serious 5 Epidural infusion of anaesthetic administered intravenously to a woman in labour. No patient harm, high-risk event. Although colour-coded, epidural and IV connections are inter-changeable. Credentialing/training of inconsistent. Double of correct connection not required. Assess potential for introducing locking system. Revise policy and training to require bedside double-checking of the infusion and connection. In progress. In progress.
SSE_cases_2010_11_FINALv1.docx