Serious 4C Unrecognised patient Patient was subject to decreased The patient’s ongoing pain deterioration due to respiratory drive possibly due to management plan was deactivated inadequate monitoring. sedatives given and it is possible by the Hospital Pain Team. there was a primary aspiration A ward to be completed of all event which compromised the observation charts and medication patient’s ventilation. charts to identify compliance with The respiratory depression was PCA protocol. treated and the patient recovered. Review of the management and Patient-controlled analgesia communication of patients under protocol not followed. both long-standing and acute medical teams. Serious 9 Inpatient assaulted by Patient who assaulted was The patient, as much as is practical, another inpatient appropriately treated and be managed in the community setting requiring emergency protection of others was managed where there is less contact with other treatment. by limited access to the ward with vulnerable patients. tight controls to ensure others’ safety, however this patient’s level of aggression was unpredictable. Serious 4C Unrecognised patient Investigation under way. deterioration due to inadequate monitoring. Serious 5 Medication error Incorrect dose of opioid Immediate Hospital Safety Alert Pharmacy currently reviewing involving a higher dose prescribed which resulted in the disseminated to always prescribe medication policy. of opioid being administration of five times liquids in milligrams because of the administered, resulting patient’s normal dose. different strengths available. in patient being treated Patient charted 37mL instead of Use of this medicine requiring in the high 37mg. medicine reconciliation be part of dependency unit. prescribing policy and included in Correct opioid dose not reconciled orientation for all medical staff. with patients prescriber. Nursing staff are to administer liquid medications only if prescribed in milligrams.
Serious 4C Unrecognised patient deterioration due to inadequate monitoring. Patient was subject to decreased respiratory drive possibly due to sedatives given and it is possible there was a primary aspiration event which compromised the patient’s ventilation. The respiratory depression was treated and the patient recovered. Patient-controlled analgesia protocol not followed. The patient’s ongoing pain management plan was deactivated by the Hospital Pain Team. A ward to be completed of all observation charts and medication charts to identify compliance with PCA protocol. Review of the management and communication of patients under both long-standing and acute medical teams. Serious 9 Inpatient assaulted by another inpatient requiring emergency treatment. Patient who assaulted was appropriately treated and protection of others was managed by limited access to the ward with tight controls to ensure others’ safety, however this patient’s level of aggression was unpredictable. The patient, as much as is practical, be managed in the community setting where there is less contact with other vulnerable patients. Serious 4C Unrecognised patient deterioration due to inadequate monitoring. Investigation under way. Serious 5 Medication error involving a higher dose of opioid being administered, resulting in patient being treated in the high dependency unit. Incorrect dose of opioid prescribed which resulted in the administration of five times patient’s normal dose. Patient charted 37mL instead of 37mg. Correct opioid dose not reconciled with patients prescriber. Immediate Hospital Safety Alert disseminated to always prescribe liquids in milligrams because of the different strengths available. Use of this medicine requiring medicine reconciliation be part of prescribing policy and included in orientation for all medical staff. Nursing staff are to administer liquid medications only if prescribed in milligrams. Pharmacy currently reviewing medication policy.
SSE-cases-2010-11-FINALv1.docx