Serious 4B Equipment Suction canister damaged when the bed Revise suction canister height at the In progress. deficiencies during moved up. in all inpatient wards. two ward Use of plastic bag dust can dislodge Plastic bags not permitted to suction resuscitations: Implemented. suction. canisters. suction system Difficult re-assembly of suction unit. High quality laryngoscopes to be brought laryngoscope to ward resuscitations, rather than kept Implemented. Older laryngoscope style with risks of on ward trolleys. manual ventilation loss of locking pin, loose light bulb, and bag. incompatible blades. Full revision of resuscitation tray, trolley Revision complete; roll-out and checking/re-stocking process. Deaths of two Checking and restocking of resuscitation of new system in progress. patients involved and emergency trolley is were not directly inconsistent. caused by these equipment issues, but risk was increased. Sentinel 4B Remotely monitored Delay in advising ward; coronary care Change to calling co-ordinator cellphone Implemented patient sustained staff called unattended ward phone. rather than ward phone. cardiac arrest. Ward staff unfamiliar with response Standard messages/phrasing to be used Probable delay in Implemented systems. when Code is called from Coronary Care resuscitation; Unit (CCU). Organisation -wide influence on fatal Inadequate communication with family. programme in progress resuscitation outcome Review of bereavement processes and not clear. resources. Serious 4C Delay in emergency Delayed recognition; poor Protocol for suspected or actual uterine Complete. response for uterine communication; inadequate perforation. perforation after operative physiologic monitoring. Standardised post-operative physiologic termination of Implemented. Unfamiliarity with emergency call monitoring. pregnancy. systems due to historic independence of Staff education and training on service. emergency call systems. Complete.
Serious 4B Equipment deficiencies during two ward resuscitations: suction system laryngoscope manual ventilation bag. Deaths of two patients involved were not directly caused by these equipment issues, but risk was increased. Suction canister damaged when the bed moved up. Use of plastic bag dust can dislodge suction. Difficult re-assembly of suction unit. Older laryngoscope style with risks of loss of locking pin, loose light bulb, and incompatible blades. Checking and restocking of resuscitation and emergency trolley is inconsistent. Revise suction canister height at the in all inpatient wards. Plastic bags not permitted to suction canisters. High quality laryngoscopes to be brought to ward resuscitations, rather than kept on ward trolleys. Full revision of resuscitation tray, trolley and checking/re-stocking process. In progress. Implemented. Implemented. Revision complete; roll-out of new system in progress. Sentinel 4B Remotely monitored patient sustained cardiac arrest. Probable delay in resuscitation; influence on fatal resuscitation outcome not clear. Delay in advising ward; coronary care staff called unattended ward phone. Ward staff unfamiliar with response systems. Inadequate communication with family. Change to calling co-ordinator cellphone rather than ward phone. Standard messages/phrasing to be used when Code is called from Coronary Care Unit (CCU). Review of bereavement processes and resources. Implemented Implemented Organisation -wide programme in progress Serious 4C Delay in emergency response for uterine perforation after termination of pregnancy. Delayed recognition; poor communication; inadequate physiologic monitoring. Unfamiliarity with emergency call systems due to historic independence of service. Protocol for suspected or actual uterine perforation. Standardised post-operative physiologic monitoring. Staff education and training on emergency call systems. Complete. Implemented. Complete. operative
SSE_cases_2010_11_FINALv1.docx