Serious 6 Inpatient fall resulting The falls prevention plan was The use of alarms should be in a fractured hip. developed and followed to best continued as long as a high risk of care for the patient. falls exists and their use can be justified. Consideration was given to the residential context the patient was Consideration should be given to the being discharged to and hence purchase of hip protector pads to the falls alarm was discontinued decrease the likelihood of a fall just prior to the fall. resulting in a hip fracture. Protective hip pads, although not able to prevent the risk of could minimise the risk of fractures resulting from falls. Serious 4B Management of Investigation under way. mother in labour in the community requiring urgent treatment. Sentinel 11 Inpatient Possibility that the patient Mental health staff to have education Co-Existing Problems Working subsequent to taking obtained Methadone for from the community alcohol and drug Group is meeting regularly and Methadone obtained recreational use while on service about the high risks attention is being given to the illegally. approved ward leave. associated with recreational development of a broad skill set methadone use. among MH staff which will include Patient did not present with early addiction issues. warning signs of Methadone The Co-existing Problems Working toxicity, therefore patient was only Group will consider the inclusion of observed every 30 minutes methadone toxicity as a subject in overnight according to protocol. the development of the upcoming education. A fact sheet on methadone toxicity be developed for patients identified as current or potential illicit methadone users.
Serious 6 Inpatient fall resulting in a fractured hip. The falls prevention plan was developed and followed to best care for the patient. Consideration was given to the residential context the patient was being discharged to and hence the falls alarm was discontinued just prior to the fall. Protective hip pads, although not able to prevent the risk of could minimise the risk of fractures resulting from falls. The use of alarms should be continued as long as a high risk of falls exists and their use can be justified. Consideration should be given to the purchase of hip protector pads to decrease the likelihood of a fall resulting in a hip fracture. Serious 4B Management of mother in labour in the community requiring urgent treatment. Investigation under way. Sentinel 11 Inpatient subsequent to taking Methadone obtained illegally. Possibility that the patient obtained Methadone for recreational use while on approved ward leave. Patient did not present with early warning signs of Methadone toxicity, therefore patient was only observed every 30 minutes overnight according to protocol. Mental health staff to have education from the community alcohol and drug service about the high risks associated with recreational methadone use. The Co-existing Problems Working Group will consider the inclusion of methadone toxicity as a subject in the development of the upcoming education. A fact sheet on methadone toxicity be developed for patients identified as current or potential illicit methadone users. Co-Existing Problems Working Group is meeting regularly and attention is being given to the development of a broad skill set among MH staff which will include addiction issues.
SSE-cases-2010-11-FINALv1.docx