Serious 4C Stillbirth following Review identified that the Review recommended review of The report was provided to the induction at 39 weeks cardiotocograph (CTG service education and practice related family and a subsequent meeting – gestation. baby’s heart tracing) reading to cardiotocograph interpretation. held to discuss the report. was not reassuring and Regional approach to training in indicated the need to review progress and planned roll-out of and change the plan of care. cardiotocograph/Fetal Review did not conclude that Surveillance Education Training the adverse outcome could Passport for relevant staff at have been averted and noted CCDHB in place. that the opportunity for intervention may have been missed. Serious 4C Patient developed Review identified a five-day Review recommended an apology be The report was provided to the paraplegia resulting delay in identification of the made to the family, the epidural policy family and a subsequent meeting from epidural patient’s loss of lower limb be amended, staff education to learn held to discuss the report. haematoma during sensation and implementation from the event and review of existing The Ward Advanced Analgesia epidural infusion of appropriate treatment, documentation to specify action Observation Chart and ICU therapy. during which time the patient required when any unusual or Observation charts have been developed permanent persistent sensory or motor deficit is modified. Policy and staff paralysis. During this period present. education actions are in progress. changes were initially attributed to the epidural infusion. Serious 5 Prolonged fetal The review team identified that Review recommended and practice The report was provided to the bradycardia (low fetal the mother received a bolus of change related to syntocinon family. Syntocinon Infusion Policy heart rate) due to a syntocinon due to a human administration. updated including specific process bolus dose of error in the set-up of the for checking and pump set up. syntocinon during labour syntocinon infusion through a Staff refresher education re that resulted in the pump. woman requiring an Management of Healthcare emergency caesarean. Incidents/ Open Communication Policies completed.
Serious 4C Stillbirth following induction at 39 weeks gestation. Review identified that the cardiotocograph (CTG – baby’s heart tracing) reading was not reassuring and indicated the need to review and change the plan of care. Review did not conclude that the adverse outcome could have been averted and noted that the opportunity for intervention may have been missed. Review recommended review of service education and practice related to cardiotocograph interpretation. The report was provided to the family and a subsequent meeting held to discuss the report. Regional approach to training in progress and planned roll-out of cardiotocograph/Fetal Surveillance Education Training Passport for relevant staff at CCDHB in place. Serious 4C Patient developed paraplegia resulting from epidural haematoma during epidural infusion therapy. Review identified a five-day delay in identification of the patient’s loss of lower limb sensation and implementation of appropriate treatment, during which time the patient developed permanent paralysis. During this period changes were initially attributed to the epidural infusion. Review recommended an apology be made to the family, the epidural policy be amended, staff education to learn from the event and review of existing documentation to specify action required when any unusual or persistent sensory or motor deficit is present. The report was provided to the family and a subsequent meeting held to discuss the report. The Ward Advanced Analgesia Observation Chart and ICU Observation charts have been modified. Policy and staff education actions are in progress. Serious 5 Prolonged fetal bradycardia (low fetal heart rate) due to a bolus dose of syntocinon during labour that resulted in the woman requiring an emergency caesarean. The review team identified that the mother received a bolus of syntocinon due to a human error in the set-up of the syntocinon infusion through a pump. Review recommended and practice change related to syntocinon administration. The report was provided to the family. Syntocinon Infusion Policy updated including specific process for checking and pump set up. Staff refresher education re Management of Healthcare Incidents/ Open Communication Policies completed.
SSE_cases_2010_11_FINALv1.docx