Sentinel 4D A planned removal of the Root analysis review completed. Report in draft. gall bladder was complicated by a bowel perforation. The patient died unexpectedly 11 days later. Serious 4D Patient’s wound drains Patient was cared for in another surgical Continue review of surgical bed requirements Action were removed prematurely, specialty ward post-operatively where and ensure the issues surrounding this event be under way. requiring a return to the staff were less familiar with the made known to the group reviewing surgical bed operating theatre to have care of breast surgery requirements. the drains reinserted under patients. general anaesthetic. Instructions with regards to drain removal were misunderstood. Serious 5 Concentrated potassium Incorrect administration of concentrated No concentrated potassium will be held in any Action was administered as a potassium. clinical area. under way. bolus without resultant harm. Serious 8 Mental health inpatient No preventable causal factors identified. No recommendations. absconded from care. Potential for serious harm. Serious 11 A severe (stage 4) pressure Timing issues/delays occurred in the All staff to complete revision of pressure area Actions injury developed during reporting of the pressure injury and assessment and prevention, including the use of under way episode. ordering and provision of pressure-relieving equipment. relieving equipment. Serious 11 A severe (stage 4) pressure Timing issues/delays occurred in the All staff to complete revision of pressure area injury developed during reporting of the pressure injury and assessment and prevention, including the use of inpatient episode. ordering and provision of pressure equipment. equipment.
Sentinel 4D A planned removal of the gall bladder was complicated by a bowel perforation. The patient died unexpectedly 11 days later. Root analysis review completed. Report in draft. Serious 4D Patient’s wound drains were removed prematurely, requiring a return to the operating theatre to have the drains reinserted under general anaesthetic. Patient was cared for in another surgical specialty ward post-operatively where staff were less familiar with the care of breast surgery patients. Instructions with regards to drain removal were misunderstood. Continue review of surgical bed requirements and ensure the issues surrounding this event be made known to the group reviewing surgical bed requirements. Action under way. Serious 5 Concentrated potassium was administered as a bolus without resultant harm. Incorrect administration of concentrated potassium. No concentrated potassium will be held in any clinical area. Action under way. Serious 8 Mental health inpatient absconded from care. Potential for serious harm. No preventable causal factors identified. No recommendations. Serious 11 A severe (stage 4) pressure injury developed during episode. Timing issues/delays occurred in the reporting of the pressure injury and ordering and provision of equipment. All staff to complete revision of pressure area assessment and prevention, including the use of pressure-relieving equipment. Actions under way Serious 11 A severe (stage 4) pressure injury developed during inpatient episode. Timing issues/delays occurred in the reporting of the pressure injury and ordering and provision of equipment. All staff to complete revision of pressure area assessment and prevention, including the use of pressure relieving equipment.
SSE_cases_2010_11_FINALv1.docx