Serious 1 Patient was scheduled for Absence of a clearly defined Implement the Time Out before By the end of July 2011, 1200+ a bronchoscopy. Patient process for checking and procedure/sedation checklist. staff had received education on consented for and confirming patient identity and formal identification of patients Review of consenting process in the received a gastroscopy in indications for the procedure with this was done in conjunction – Endoscopy Unit for patients who have the patient prior to sedation. with: English as a second language. No clearly defined processes for updating policy and consenting patients who have procedure English as a second language. roll-out of a standardised method of face-to-face engagement with patients and whānau roll-out of the modified World Health Organization Time Out procedures checklist in Endoscopy. Serious 4A Treatment delayed for a Because the test for heart Multidisciplinary governance group to A multidisciplinary at ‘patient patient with severe chest damage (troponin) was negative, be set up to manage issues relating to risk’ governance group has pain resulting in the the severe pain was not management of the at risk’. been set up. ‘patient patient sustaining recognised as being potentially Ward staff to be up-skilled in Education and training for significant cardiac cardiac in origin and care was management of acute coronary nursing staff on the ward is damage. not escalated. syndrome and the basic interpretation ongoing. electrocardiogram (ECG) ECG changes. A training session was given to signs of an anterior myocardial Training session for house surgeons on house surgeons by a senior infarct (heart attack) were not anterior myocardial infarct and medical officer (SMO) and will initially recognised by nursing interpretation of ECGs. be ongoing as part of the and medical staff. annual orientation programme The patient was discharged for the new house surgeons home following treatment. intake.
Serious 1 Patient was scheduled for a bronchoscopy. Patient consented for and received a gastroscopy in Absence of a clearly defined process for checking and confirming patient identity and indications for the procedure with the patient prior to sedation. No clearly defined processes for consenting patients who have English as a second language. Implement the Time Out before procedure/sedation checklist. Review of consenting process in the Endoscopy Unit for patients who have English as a second language. By the end of July 2011, 1200+ staff had received education on formal identification of patients – this was done in conjunction with: updating policy and procedure roll-out of a standardised method of face-to-face engagement with patients and whānau roll-out of the modified World Health Organization Time Out procedures checklist in Endoscopy. Serious 4A Treatment delayed for a patient with severe chest pain resulting in the patient sustaining significant cardiac damage. Because the test for heart damage (troponin) was negative, the severe pain was not recognised as being potentially cardiac in origin and care was not escalated. electrocardiogram (ECG) signs of an anterior myocardial infarct (heart attack) were not initially recognised by nursing and medical staff. The patient was discharged home following treatment. Multidisciplinary governance group to be set up to manage issues relating to management of the ‘patient at risk’. Ward staff to be up-skilled in management of acute coronary syndrome and the basic interpretation ECG changes. Training session for house surgeons on anterior myocardial infarct and interpretation of ECGs. A multidisciplinary ‘patient at risk’ governance group has been set up. Education and training for nursing staff on the ward is ongoing. A training session was given to house surgeons by a senior medical officer (SMO) and will be ongoing as part of the annual orientation programme for the new house surgeons intake.
SSE-cases-2010-11-FINALv1.docx