Serious 5 A 14-month old child was Fragmented communication and Strengthen clinical handover process Completed. administered too much handover re child’s hydration status. with a primary focus on the documented intravenous fluid during a information, from Child Health to No agreed interdepartmental process procedure under general Anaesthetics. related to perioperative management anaesthetic, resulting in in acute paediatric patients. increased inpatient stay. Serious 5 Chemotherapy intravenous The process for preparing, storing and Chemotherapy protocols to be Completed. medication administered to checking of chemotherapy medication standardised. the wrong patient, resulting was not followed and did not provide Develop process to track chemotherapy in increased inpatient stay. clarity around this process. medication delivery and administration. Serious 5 One unit of frozen Existing protocols for checking of blood Audit compliance with protocols. Completed. plasma given in error. components prior to administration were Ensure all staff complete mandatory not followed. update on blood component administration protocols. Sentinel 2 Suspected suicide while on There was incomplete risk assessment Leave form to be adjusted to include a Completed. day leave from inpatient documentation leading to gaps in process for voluntary patients. unit. knowledge regarding the patient’s risk Assessment of mental status to be levels. There was also lack of clarity documented on leave form. regarding leave processes for voluntary patients. Serious 3 Gauze swab missing from Portable X-ray machine not available in No recommendations made. Completed. count at end of procedure. theatre before patient’s abdomen was Patient examined and swab closed. Taken to X-ray after surgical not found. Abdomen closed closure and swab identified. and X-ray performed. Swab identified in abdomen therefore patient required further surgery to remove swab.
Serious 5 A 14-month old child was administered too much intravenous fluid during a procedure under general anaesthetic, resulting in increased inpatient stay. Fragmented communication and handover re child’s hydration status. No agreed interdepartmental process related to perioperative management in acute paediatric patients. Strengthen clinical handover process with a primary focus on the documented information, from Child Health to Anaesthetics. Completed. Serious 5 Chemotherapy intravenous medication administered to the wrong patient, resulting in increased inpatient stay. The process for preparing, storing and checking of chemotherapy medication was not followed and did not provide clarity around this process. Chemotherapy protocols to be standardised. Develop process to track chemotherapy medication delivery and administration. Completed. Serious 5 One unit of frozen plasma given in error. Existing protocols for checking of blood components prior to administration were not followed. Audit compliance with protocols. Ensure all staff complete mandatory update on blood component administration protocols. Completed. Sentinel 2 Suspected suicide while on day leave from inpatient unit. There was incomplete risk assessment documentation leading to gaps in knowledge regarding the patient’s risk levels. There was also lack of clarity regarding leave processes for voluntary patients. Leave form to be adjusted to include a process for voluntary patients. Assessment of mental status to be documented on leave form. Completed. Serious 3 Gauze swab missing from count at end of procedure. Patient examined and swab not found. Abdomen closed and X-ray performed. Swab identified in abdomen therefore patient required further surgery to remove swab. Portable X-ray machine not available in theatre before patient’s abdomen was closed. Taken to X-ray after surgical closure and swab identified. No recommendations made. Completed.
SSE-cases-2010-11-FINALv1.docx