Tairawhiti District Health www.tdh.org.nz Tairawhiti DHB has adopted the Severity Assessment Code (SAC) rating terminology in accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with and events. ‘Sentinel’ ‘Serious’ The SSE report stated that Tairawhiti had six SSEs. Following review, one of these cases was the suicide of a community mental health and addiction services patient in the community, so should not have been included in the overall numbers. Serious Event Description of event Review findings Recommendations/actions Follow-up or code sentinel Serious 6 Fall causing injury to Inconsistent communication Revise the handover process between inpatient Vacancy filled. eye and subsequent processes for patients wards and the rehab unit and consider handover policy reviewed and loss of vision in that attending the Day of sheet. implemented, including: eye. Rehabilitation Unit (DRU). Visual of identifying patients at risk of falling new falls risk form and Clinical did not in line with new Falls Policy. identification stickers as accompany patient to the Clinical to accompany patients to the rehab an easy communication DRU. unit. method to identify Out-dated falls policy and patients at risk of falling Implement revised Falls Policy. hence varying handover between ward 9 understanding of falls risk. Training regarding falls risk and prevention and DRU standardised provided to all levels of staff who care for at risk DRU nurse vacancy. patients, at orientation and updates thereafter. clinical notes accompany patients attending DRU.
Tairawhiti District Health www.tdh.org.nz Tairawhiti DHB has adopted the Severity Assessment Code (SAC) rating terminology in accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with ‘Sentinel’ and ‘Serious’ events. The SSE report stated that Tairawhiti had six SSEs. Following review, one of these cases was the suicide of a community mental health and addiction services patient in the community, so should not have been included in the overall numbers. Serious or sentinel Event code Description of event Review findings Recommendations/actions Follow-up Serious 6 Fall causing injury to eye and subsequent loss of vision in that eye. Inconsistent communication processes for patients attending the Day of Rehabilitation Unit (DRU). Clinical did not accompany patient to the DRU. Out-dated falls policy and hence varying understanding of falls risk. DRU nurse vacancy. Revise the handover process between inpatient wards and the rehab unit and consider handover sheet. Visual of identifying patients at risk of falling in line with new Falls Policy. Clinical to accompany patients to the rehab unit. Implement revised Falls Policy. Training regarding falls risk and prevention provided to all levels of staff who care for at risk patients, at orientation and updates thereafter. Vacancy filled. policy reviewed and implemented, including: new falls risk form and identification stickers as an easy communication method to identify patients at risk of falling handover between ward 9 and DRU standardised clinical notes accompany patients attending DRU.
SSE-cases-2010-11-FINALv1.docx