Serious 6 Inpatient fall resulting prevention risk planning was Documentation standards and Ongoing of the falls prevention in fractured knee. not completed prior to the patients expectations to be reinforced to staff programme to ensure it is being fall; however, the physiotherapist via the charge nurse managers and utilised correctly. had assessed the patient as being educators on falls prevention and safe to independently mobilise care planning. Serious 5 Intravenous cross The Fentanyl syringe was not Education sessions held for all to The education session focused on contamination of a discarded at the end of the duty reinforce the principals of the IV ensuring practice change was medicine (Fentanyl) and was subsequently used on policy and to provide instruction on occurring and to provide a between two patients. another patient. correct discarding of controlled question/answer session for medications. queries and options on how to The Intravenous Medication work within the scope of the policy. Policy was not correctly followed. Controlled medication cupboard checks will be undertaken to ensure any leftover medications are discarded according to policy at the end of each shift. Sentinel 11 Inpatient death. Awaiting findings from the coroner as it appears this death may have been due to natural causes. Serious 6 Inpatient fall resulting The patient was treated as high All available preventative measures in a fractured leg risk according to the falls were in place therefore there are no (femur) requiring prevention protocol and the fall recommendations. surgery. Patient was multi-factorial. subsequently died. It does not appear that the fall contributed to the patient’s death. Serious 8 Patient absconded and Investigation way. an alleged assault occurred.
Serious 6 Inpatient fall resulting in fractured knee. prevention risk planning was not completed prior to the patients fall; however, the physiotherapist had assessed the patient as being safe to independently mobilise Documentation standards and expectations to be reinforced to staff via the charge nurse managers and educators on falls prevention and care planning. Ongoing of the falls prevention programme to ensure it is being utilised correctly. Serious 5 Intravenous cross contamination of a medicine (Fentanyl) between two patients. The Fentanyl syringe was not discarded at the end of the duty and was subsequently used on another patient. The Intravenous Medication Policy was not correctly followed. Education sessions held for all to reinforce the principals of the IV policy and to provide instruction on correct discarding of controlled medications. Controlled medication cupboard checks will be undertaken to ensure any leftover medications are discarded according to policy at the end of each shift. The education session focused on ensuring practice change was occurring and to provide a question/answer session for queries and options on how to work within the scope of the policy. Sentinel 11 Inpatient death. Awaiting findings from the coroner as it appears this death may have been due to natural causes. Serious 6 Inpatient fall resulting in a fractured leg (femur) requiring surgery. Patient subsequently died. The patient was treated as high risk according to the falls prevention protocol and the fall was multi-factorial. It does not appear that the fall contributed to the patient’s death. All available preventative measures were in place therefore there are no recommendations. Serious 8 Patient absconded and an alleged assault occurred. Investigation way.
SSE_cases_2010_11_FINALv1.docx