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					   District Health Board
Serious and Sentinel Events
          2010/11
                              Published in February 2012 by the
                             Health Quality and Safety Commission
                                   Wellington, New Zealand



This document is available on the Health Quality and Safety Commission website www.hqsc.govt.nz
Codes used to classify events
1       Wrong patient, site or procedure
2       Suicide of an inpatient
3       Retained instruments or swabs
                                                     1
4       Clinical management issue, plus sub-code(s):

        A       Diagnosis (including delayed and misdiagnosis)
        B       Treatment (including delayed and inadequate)
        C       Monitoring/observations (not performed and/or actioned)
        D       Procedure associated incident or complication
        E       Investigation (delayed, not ordered or actioned)
        F       Discharge and transfer
        G       Other

5       Medication error
6       Falls
                                   2
7       Blood transfusion reaction
8       AWOL/missing patient
9       Physical assault on patient
10      Delays in transfer
11      Other
12      Hospital acquired infection


A serious adverse event is one that requires significant additional treatment, but is not life threatening and has not resulted in a major loss of function. A sentinel
adverse event is life threatening or has led to an unanticipated death or major loss of function.

District Health Boards (DHBs) have classified the severity of the events either as Sentinel and Serious, or as Severity Assessment Code (SAC) 1 or 2; for the
purpose of this report, these classifications are broadly comparable.




1
    Some incidents involved more than one event category.
2
    No blood transfusion reaction events were reported in 2010/11 as serious or sentinel (SAC1 or 2) events.


                                                                                             Summary of DHB Serious and Sentinel Event Report 2010/11                 i
Glossary
Anticoagulant   Medicine used to prevent or slow normal clotting process, also known as ‘blood thinner’.
Ascites         Fluid in the abdomen (peritoneum)
Bronchoscopy    Endoscopy to view the lungs
CCU             Coronary Care Unit
CT/CAT scan     Computerised Tomography, Computerised Axial Tomography scan. ‘Contrast’ is sometimes given to the patient during a CT scan, a chemical
                that enhances the X-ray image.
CTG             Cardiotocograph. Equipment that monitors fetal heart rate and the contractions of the mother’s uterus
CYFS            Child Youth and Family Services
ECG             Electrocardiogram, used to record function of heart
ED              Emergency department
ENT             Ear, nose and throat specialty
Epidural        Injection or infusion into the spine, usually for anaesthesia, but also other drugs such as chemotherapy
Gastroscopy     Procedure using a fibre-optic scope that views the stomach.
GCS             Glasgow Coma Scale. An assessment of conscious level.
IM              Intra-muscular, usually referring to an injection or infusion
ICU             Intensive Care or Intensive Therapy unit
IV              Intravenous, usually referring to an injection or infusion
MRI scan        Magnetic Resonance Imaging scan
Pyrexia         High body temperature
RMO             Responsible medical officer. Generally, a doctor below the grade of consultant or senior medical officer (SMO)
SAC             Severity Assessment Code, used to categorise severity of incidents
SMO             Senior Medical Officer, also referred to as Consultant
WHO             World Health Organization




                                                                                     Summary of DHB Serious and Sentinel Event Report 2010/11            ii
                                                                                                                                         Northland District Health Board



Northland District Health Board
www.northlanddhb.org.nz

 Serious or   Event   Description of event                 Review findings                        Recommendations/actions                           Follow-up
  sentinel    code

  Serious       5     Patient                  Omission of patient identification checks     Revisit medication safety and                  All undertaken.
                      misidentification        during medication administration.             administration of high-risk drugs for all
                      resulted in wrong                                                      Emergency Department (ED) staff.
                                               Staff workload management and re-
                      patient receiving                                                      Review relevance to ED environment.
                                               allocation processes inadequate.
                      medication.
                                                                                             Review model of care.
                                               Handover processes did not provide
                                               relevant information clearly.                 Formalise handover – use SBARR
                                                                                             (Situation, Background, Assessment,
                                                                                             Recommendation, Response) tool.
                                                                                             Revise overload code plan to include
                                                                                             staff workload management.

  Sentinel    4 B&C   Unexpected birth at      Inadequate communication occurred             SBARR – Situation, Background,                 Handover is structured by
                      home. Unclear            between the health professionals              Assessment, Recommendation,                    using standard
                      communication            involved in the care pathway; this had        Response – (or equivalent) utilised to         documentation on delivery
                      between ambulance        the potential to impact on the overall        convey handover information.                   suite.
                      officers and hospital    outcome.
                                                                                             Single set of clinical notes.                  Protocols are easy to
                      staff, baby requiring
                                               Inadequate documentation.                                                                    access, both electronically
                      unanticipated                                                          Consider opportunities for multiagency
                                                                                                                                            and in hard copy.
                      admission to intensive                                                 neonatal resuscitation education.
                      care unit.                                                                                                            Flow chart developed for
                                                                                             Adapt the ED ambulance call record to
                                                                                                                                            use with the ambulance
                                                                                             meet the need of the maternity services.
                                                                                                                                            radio.
                                                                                             Reinforce the use of the emergency call
                                                                                                                                            Monthly Basic Life Support
                                                                                             system in hospital to seek any
                                                                                                                                            updates including
                                                                                             emergency assistance.
                                                                                                                                            emergency call processes.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11                    1
                                                                                                                                    Northland District Health Board


Serious or   Event   Description of event                Review findings                         Recommendations/actions                       Follow-up
 sentinel    code

 Sentinel      5     Patient given a 10-     Distraction of staff, associated with ward    Review processes for safe use of insulin    Diabetes specialist nurses
                     times overdose of two   rebuilding and refurbishment.                 in ward; eg, using only insulin pens.       attended pharmacy and
                     different types of                                                                                                ward to do training.
                                             Staff elected not to use insulin pen for      Educate nurses about correct use of
                     insulin.
                                             administration.                               abbreviations and no use of ‘u’ in any    Insulin pens which are
                                                                                           documentation.                            able to give half units are
                                             Insulin not stocked on ward.
                                                                                                                                     now more freely available.
                                                                                           Educate doctors on safe insulin
                                             Dose of insulin to be given written as ‘u’                                              Improved staff awareness
                                                                                           prescribing as part of medical staff (RMO
                                             instead of ‘units’; general acceptance of                                               of their utility and use
                                                                                           – responsible medical officer) education
                                             wrong abbreviation by doctors and                                                       monitored through auditing
                                                                                           programme.
                                             nurses.                                                                                 of medication charts.
                                                                                           Develop systematic process for
                                             Doses prescribed as ‘1U’ and ‘2U’, and                                                  Safe prescribing practices
                                                                                           identifying and managing staff workload
                                             misread as ‘10’ and ‘20’ respectively.                                                  (eg, use of full word 'units')
                                                                                           issues on real time basis.
                                                                                                                                     are covered in pharmacy
                                             Perceived high staff workload.                                                          teaching to doctors.
                                                                                                                                       Safety alert sent out about
                                                                                                                                       necessity to prescribe
                                                                                                                                       using the word 'units'
                                                                                                                                       rather than using an
                                                                                                                                       abbreviation.
                                                                                                                                       Care Capacity
                                                                                                                                       Management programme
                                                                                                                                       will assist in determining
                                                                                                                                       workload issues and better
                                                                                                                                       matching staff resources
                                                                                                                                       to demand.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11                2
                                                                                                                                    Northland District Health Board


Serious or   Event    Description of event                Review findings                         Recommendations/actions                      Follow-up
 sentinel    code

 Serious       1     Wrong type of           Human error – misreading of labels             Review storage and labelling of implants. Boxes of equipment
                     orthopaedic implant     despite use of correct double checking                                                   relabelled.
                                                                                            Identify if any other barrier for implant
                     inserted during         procedures.
                                                                                            selection possible.                       Storage reviewed.
                     surgery, requiring
                                             Limited experience of staff may have
                     subsequent                                                             Ensure staff know how to access            Staff awareness enhanced
                                             contributed.
                     replacement                                                            relevant resource information.             re hazards of reliance on
                     (intramedullary rod).   Labelling of implants similar for different                                               checking.
                                                                                            Use closed looped communication
                                             types.
                                                                                            integrated into the double-checking        Ongoing staff training.
                                             Different types of implants stored in          process to add an auditory component
                                             close proximity.                               as well as visual.
                                                                                            Review pre-operative checking process
                                                                                            regarding availability of correct
                                                                                            equipment.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11              3
                                                                                                                                      Waitemata District Health Board



Waitemata District Health Board
www.waitematadhb.govt.nz

 Serious or   Event   Description of event                  Review findings                        Recommendations/actions                        Follow-up
  sentinel    code

  Serious       4D    Blood cross-matched       Emergency situation at change of shift       Processes reviewed:                          Recommendations/
                      for mother (diagnosis     with multiple teams, resulting in                                                         corrective actions
                      of placental              inadequate checking process.                  requesting blood for a baby                implemented.
                      abruption) was given
                                                No adverse harm to baby.                      emergency call in theatre
                      to baby in error.
                                                                                              cord gas in resuscitation situation.

  Serious       4D    Patient discharged        Patient had repeated bleeding with low       Education around ordering ultrasound for Completed.
                      with retained products    haemoglobin level of 71.                     retained products if there is repeated
                      (placenta) after birth.                                                bleeding.
                                                Readmitted with persistent bleeding and
                      No ultrasound was
                                                plan for further surgery.
                      conducted prior to
                      discharge.                Experienced a cardiac arrest in operating
                                                theatre. Patient fully recovered.

  Sentinel      4A    Patient was               CTG was misread by independent               All CTGs to be reviewed by a clinical
                      discharged in early       midwife.                                     charge midwife (CCM) or a senior
                      labour when                                                            medical officer (SMO).
                                                Midwife called and was told that no fetal
                      cardiotocograph
                                                movements noted since woman had
                      (CTG) was misread.
                                                gone home. (Discharge was 11.28am,
                                                readmission at 6pm.)
                                                Reassessment and fetal death
                                                confirmed.




                                                                                            Summary of DHB Serious and Sentinel Event Report 2010/11               4
                                                                                                                                     Waitemata District Health Board


Serious or   Event   Description of event                 Review findings                        Recommendations/actions                          Follow-up
 sentinel    code

 Sentinel      5     Medication               Critically unwell on admission with major    Approved medication administration            Safe Medicines Steering
                     administration error.    cardio-respiratory and other co-             procedures reinforced with nurses             Group monitors safety
                     Wrong medication         morbidities.                                 across the DHB.                               strategy initiatives, errors
                     administered.                                                                                                       trends and significant
                                              Nurse administered medications
                                                                                                                                         incidents.
                                              intended for another patient due to mix-
                                              up with prescription sheet.
                                              The case has been referred to the
                                              Coroner (awaiting confirmed cause of
                                              death).

 Sentinel      5     Medication               Prescription misread by the nurse            External expert review of investigation       Recommendations being
                     administration error.    administering medication.                    undertaken.                                   implemented.
                     Small dose was
                                              Patient unwell with major cardio-            Review of practice for verbal                 Safe Medicines Steering
                     prescribed, but
                                              respiratory and other co-morbidities.        communication of unusually small (or          Group monitors safety
                     standard dose
                                              Due to very limited cardiovascular           large) prescriptions to reduce the risk of    strategy initiatives, errors
                     administered.
                                              reserve this single dose was associated      misreading error.                             trends and significant
                                              with circulatory failure, which was                                                        incidents.
                                                                                           Implement national medication chart with
                                              unresponsive to treatment.
                                                                                           pre-printed decimal point.
                                              The case has been referred to the
                                                                                           Communication processes between
                                              Coroner (awaiting confirmed cause of
                                                                                           clinical teams under review.
                                              death).

 Serious       5     Medication               Adrenaline 0.5mg intramuscular               Review of emergency protocols with
                     prescription error.      injection should have been prescribed        doctor and nurses and competence
                     1mg of intravenous       and administered.                            update.
                     Adrenaline prescribed
                                              Patient experienced significant rise in      Review of 777 (emergency) call
                     and administered for
                                              blood pressure. Transferred to intensive     procedure with junior staff.
                     patient having an
                                              care unit (ICU). Cardiac impact noted.
                     anaphylactic (allergic                                                Training exercises using emergency
                     response) event.         Patient has had no long-term adverse         algorithms for cardiac arrest and
                                              effects.                                     anaphylaxis scenarios.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11                      5
                                                                                                                                   Waitemata District Health Board


Serious or   Event   Description of event                Review findings                        Recommendations/actions                        Follow-up
 sentinel    code

 Serious       4B    Inappropriate           Abdominal ascites tap performed despite      Review of rationale with doctor.
                     procedure performed.    ultrasound stating no free fluid present.
                                                                                          Reinforce communication with senior
                                             Deteriorated overnight with increasing       consultant.
                                             abdominal pain and hypotension from
                                             bowel wall haematoma. ICU admission.
                                             Discharged after rehabilitation.

 Sentinel      4A    Diagnosis error. It     Patient presented with vaginal bleeding,     Policy written for ED staff over the use of   Recommendations
                     was believed patient    and given Misoprostol to 'complete           Misoprostol.                                  implemented.
                     had passed products     miscarriage'.
                                                                                          Staff education undertaken.
                     of conception.
                                             Ultrasound showed a live fetus with fetal
                     Misoprostol given to
                                             bradycardia (slow pulse).
                     complete miscarriage.
                                             Patient given activated charcoal within
                                             12 minutes of being given Misoprostol.
                                             Later scan showed a non-viable
                                             pregnancy.

 Serious       4C    Attempted suicide.      Cleared for discharge with family by         Risk assessment reviewed with staff.          New ED department
                                             Mental Health team.                                                                        opened in March 2011.
                                                                                          Keys given so staff can readily access
                                             Requested to go to the toilet, and found     toilets in emergencies.
                                             cyanosed and unconsciousness.
                                                                                          New department and procedures
                                             Emergency action taken.
                                                                                          reduces risk.
                                             Difficulty monitoring mental health
                                             patients in previous department.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11               6
                                                                                                                                       Waitemata District Health Board


Serious or   Event   Description of event                    Review findings                        Recommendations/actions                        Follow-up
 sentinel    code

 Serious       4B    Delayed treatment.         Admitted with sepsis (infection)              ED pre-assessment prior to ward
                                                secondary to septic arthritis and             placement reviewed and staff educated
                                                necrotising fasciitis of left leg. Delayed    about expectations. ED to use North
                                                referral by primary practitioner for ICU      Shore Early Warning Score (NEWS)
                                                review. Deteriorated on ward.                 prior to transfer from ED.
                                                Transferred to regional ICU post-op for       Reinforce expectation that antibiotics
                                                cardio respiratory support secondary to       must be given on time as prescribed.
                                                multi-organ failure following four
                                                                                              Strict compliance with NEWS policy.
                                                procedures (compartmental
                                                fasciectomies).                               Increased orthopaedic registrar
                                                                                              involvement.
                                                Plastic surgery was carried out at
                                                another hospital. The patient’s leg and all Improved communication.
                                                the muscles were saved.

 Serious       6     Unwitnessed fall           Patient was admitted for alcohol              No recommendations identified.
                     resulting in head          withdrawal (Section 9 of the ADA Act
                     injury (subdural           1966). Diagnosis of sub-dural
                     haematoma) requiring       haematoma due to fall.
                     surgery.
                                                Patient required surgery to drain sub-
                                                dural haematoma.

 Serious       6     Unwitnessed fall           In seclusion due to poor mental state.        No recommendations identified.
                     resulting in cervical
                                                A CT scan of the head and cervical spine
                     fracture (broken neck)
                                                identified neck fracture (unstable C4/C5
                     requiring surgery for
                                                unifacet fracture dislocation). Taken to
                     unstable cervical
                                                theatre for surgery (C4/C5 anterior
                     spine fracture/
                                                cervical discectomy and fusion). Routine
                     dislocation.
                                                uncomplicated procedure.
                                                Admitted to ICU post-procedure.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Appropriate      Quality Improvement Initiative is under
                     in fractured hip           measures in place.                            way to implement evidence-based Falls
                     requiring surgery.                                                       Minimisation Programme.




                                                                                             Summary of DHB Serious and Sentinel Event Report 2010/11               7
                                                                                                                                     Waitemata District Health Board


Serious or   Event   Description of event                   Review findings                           Recommendations/actions                    Follow-up
 sentinel    code
                                                                                              The steering group meets monthly to
 Serious       6     Inpatient fall resulting   Assessed as high falls risk. All measures
                                                                                              monitor preventative measures put in
                     in broken rib and          in place. Patient in rehabilitation, ready
                                                                                              place, review data and trends and impact
                     lacerations.               for discharge. Cleared to mobilise
                                                                                              of awareness programme on reduction in
                                                independently by the physiotherapist.
                                                                                              first time and multiple falls.
 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Appropriate      Falls Minimisation Programme is also
                     in fractured hip           measures in place. Difficulty with            linked to two other initiatives:
                     requiring surgery.         balance.
                                                                                                      Delirium Management
                                                                                                       Improvement, and
 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Appropriate
                     in fractured hip           measures in place. On 10-minute                       Medicine Reconciliation.
                     requiring surgery.         checks. Patient suffered from confusion.
                                                                                              There is focus on sedation and
                                                                                              medication issues.
 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Not
                     in fractured hip           preventable. All measures in place.           Results of interventions showing gradual
                     requiring surgery.         Patient in rehabilitation, ready for          reduction in falls and falls with injury.
                                                discharge. Cleared to mobilise
                                                independently by the physiotherapist.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Delirium
                     in fractured hip           present, patient confused, agitated. Cot
                     requiring surgery.         sides raised – not recommended.
                                                Moved nearer nursing station.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Admitted
                     in fractured hip           following a collapse and postural
                     requiring surgery.         hypertension, osteoporosis and previous
                                                fractured neck of femur (NOF).
                                                Mobilised independently against advice.

 Serious       6     Inpatient fall resulting Assessed as high falls risk. Change in
                     in fractured pelvis and patient condition. Falls risk assessment
                     haematoma.               not repeated.
                                                Change of room contributed to
                                                confusion.




                                                                                             Summary of DHB Serious and Sentinel Event Report 2010/11             8
                                                                                                                              Waitemata District Health Board


Serious or   Event   Description of event                   Review findings                        Recommendations/actions                Follow-up
 sentinel    code

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Severe
                     in fractured hip           memory impairment. Low blood pressure
                     requiring surgery.         from medication, low sodium, poor oral
                                                nutrition.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Did not wait
                     in fractured wrist.        for health assistant while showering.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Wearing
                     in fractured hip           thromboembolic deterrent (TED)
                     requiring surgery.         stockings. Nocturnal confusion.

 Serious       6     Inpatient fall resulting   Assessed as a high falls risk. Delirium
                     in fractured hip           present.
                     requiring surgery.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Mobilised
                     in fractured hip           independently, against advice.
                     requiring surgery.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Transferring
                     in fractured hip           to bed with one assistant. Highly
                     requiring surgery.         anxious. Slipped.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Mobilised
                     in fractured elbow.        with assistance. Memory impairment.
                                                Did not wait for health assistant outside
                                                toilet door.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk.
                     in fractured hip
                     requiring surgery.

 Serious       6     Inpatient fall resulting   Assessed as high falls risk. Drowsy,
                     in fractured hip           fatigued and falling asleep during
                     requiring surgery.         assessment. Fell out of bed.




                                                                                            Summary of DHB Serious and Sentinel Event Report 2010/11       9
                                                                                                                                     Auckland District Health Board



Auckland District Health Board
Auckland DHB advised subsequent to publication of the 2010/11 Serious and Sentinel Event Report that two cases initially reported to
the Commission as SSEs had been reviewed, and were reclassified as not being serious or sentinel events.

www.adhb.govt.nz

 Serious or   Event   Description of event                  Review findings                      Recommendations/actions                        Follow-up
  sentinel    code

  Serious      4G     Child under current      Communication difficulties with Child,      Multidisciplinary ‘at risk’ discharge        Ongoing.
                      care of DHB Early        Youth and Family Services (CYFS); risk      planning and template.
                      Childhood team           not escalated.
                                                                                           Improve process for escalation if plan not
                      admitted with non-
                                                                                           followed.
                      accidental injury.
                                                                                           Communication standards for CYFS.

  Serious      1      Patient was              Platelets sent to the wrong destination.    Staff education regarding patient            Ongoing.
                      administered a                                                       identification standards.
                                               Checking process prior to administration
                      platelet transfusion
                                               was inadequate.                             Simplify documentation and move to
                      intended for a                                                                                                    Implementation
                                                                                           electronic ordering of all blood and blood
                      different patient. No                                                                                             commenced.
                                                                                           products.
                      harm, high-risk event.
                                                                                                                                        Complete.
                                                                                           Review blood bank layout and check
                                                                                           process.

  Serious      5      Epidural infusion of     Although colour-coded, epidural and IV      Assess potential for introducing counter-    In progress.
                      local anaesthetic        connections are inter-changeable.           clockwise locking system.
                      administered
                                               Credentialing/training of staff             Revise policy and training to require
                      intravenously to a                                                                                                In progress.
                                               inconsistent.                               bedside double-checking of the infusion
                      woman in labour.
                                                                                           and connection.
                                               Double check of correct connection not
                      No patient harm,
                                               required.
                      high-risk event.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11             10
                                                                                                                                          Auckland District Health Board


Serious or   Event    Description of event               Review findings                          Recommendations/actions                            Follow-up
 sentinel    code

 Serious      4B     Equipment               Suction canister damaged when the bed         Revise suction canister height at the             In progress.
                     deficiencies during     moved up.                                     bed-space in all inpatient wards.
                     two ward
                                             Use of plastic bag dust cover can             Plastic bags not permitted to cover
                     resuscitations:                                                                                                         Implemented.
                                             dislodge suction.                             suction canisters.
                      suction system
                                             Difficult re-assembly of suction unit.        High quality laryngoscopes to be brought
                      laryngoscope          Older laryngoscope style with risks of
                                                                                           to ward resuscitations, rather than kept          Implemented.
                                                                                           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       trays 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.
                     resuscitation outcome                                                 Review of bereavement processes and               programme in progress
                     not clear.                                                            resources.

 Serious      4C     Delay in emergency      Delayed recognition; poor                     Protocol for suspected or actual uterine          Complete.
                     response for uterine    communication; inadequate post-               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.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11                   11
                                                                                                                                    Auckland District Health Board


Serious or   Event   Description of event                 Review findings                        Recommendations/actions                       Follow-up
 sentinel    code

 Sentinel     4A     Lack of co-ordination   Ultrasound scan request form not sent.       Summary of specialist plan to go to          Implemented
                     of care resulting in                                                 independent midwives.
                                             Planned induction date by term was
                     stillbirth of a baby
                                             missed as full clinical notes not available. Electronic clinic record project.
                     with intrauterine                                                                                                 In progress.
                     growth retardation.     Delay in caesarean section due to            ‘Rapid rounds’ and structured handover
                                                                                                                                       Implemented.
                                             perceived need for cross-matched blood.      in Delivery Unit and Women’s
                                                                                          Assessment.
                                             Delayed communication with on-call
                                             obstetrician.                                System for early bookings for induction      Complete.
                                                                                          of labour in women with high-risk
                                                                                          pregnancies.
                                                                                          Clarify obstetrician on-call/cover           Complete.
                                                                                          arrangements.
                                                                                          Guidelines for the management of
                                                                                          women with positive antibodies who
                                                                                          need urgent surgery.

 Sentinel     8      Patient with steroid-   Lack of appreciation of risk due to poor     Revise standards for patient                 Complete.
                     induced psychosis       handover.                                    watch/security process, documentation,
                     absconded from                                                       smoking provisions and training.
                                             Inadequate definition of role for staff
                     general ward despite
                                             providing security watches.                  Explore alternative smoking options for
                     having a security
                                                                                          patients for whom nicotine replacement       In progress.
                     watch and               Limited options for smoking for
                                                                                          is inappropriate.
                     subsequently found      psychiatric patients in physical health
                     drowned.                wards.

 Serious      4A     Inappropriate           Blood tests ordered but not taken or         Review abnormal physiology guidelines.       Completed.
                     discharge from ED –     checked.
                                                                                          Remind staff to escalate if workload
                     patient returned
                                             Abnormal physiological signs were not        excessive.
                     within 24 hours with                                                                                              Completed.
                                             re-checked.
                     infection (fulminant
                     sepsis) and             High workload.
                     multiorgan failure.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11              12
                                                                                                                                       Auckland District Health Board


Serious or   Event   Description of event                   Review findings                     Recommendations/actions                            Follow-up
 sentinel    code

 Serious      5      Excessive sedative         Poor communication between ward and       Paediatric sedation policy to be reviewed       Completed
                     dose for an infant         radiology regarding use of sedation.      and updated.
                     undergoing a
                                                                                          Development of a checklist for the
                     radiology procedure,                                                                                                 In progress
                                                                                          wards.
                     causing coma for 24
                                                                                                                                          In progress
                     hours.                                                               Handover guidelines between wards and
                                                                                          Radiology staff.

 Serious      5      Infant received 10         Incorrect prescription not detected.      New design paediatric fluid prescription        In final stage of
                     times overdose of                                                    and administration chart.                       development.
                                                Chart does not highlight bolus volume
                     intravenous fluids.
                                                size.
                     Required additional
                                            No limit for volume on infusion pump.         Use of infusion pump ‘smart’ software.          Implemented.
                     treatment but no long-
                     term adverse effects.

 Serious      4D     Three-month delay in       Overdue procedure not identified.         Alert system in radiology information           Not possible with current
                     liver biopsy                                                         system (RIS) for overdue prioritisation         system.
                                                No clinical review prior to procedure.
                     performed without                                                    requests.
                     review of                  No IV access constrained treatment
                                                                                          Escalation process for review of elective
                     appropriateness            when bleeding occurred.                                                                   Ongoing.
                                                                                          procedures when patient condition has
                     when patient unwell
                                                                                          changed.
                     and at high risk.
                                                                                          Standardise practice: all patients having       Implemented.
                     Post-procedure major
                                                                                          intra-abdominal solid organ cutting
                     bleeding.
                                                                                          needle biopsy to have IV access.

 Sentinel     4A     Delayed diagnosis of       Treatment was focused on the lower leg    Revise district nursing supervision             Implemented.
                     major pressure area        ulcers.                                   model.
                     of a patient under
                                                Complex patient, no multi-disciplinary co- Revision of assessment form to be more
                     district nursing care in
                                                ordination or long-term holistic care plan. comprehensive including multi-
                     the community.
                                                                                            disciplinary information.
                     Subsequently died
                                                                                          Identification of all complex patients and
                     from severe infection.
                                                                                          assignment of primary nurse.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11                 13
                                                                                                                                     Auckland District Health Board


Serious or   Event   Description of event                  Review findings                      Recommendations/actions                          Follow-up
 sentinel    code

 Serious      4A     Missed diagnosis of      Headache was not usual for                  Policy change: Emergency medicine           Implemented.
                     ‘sentinel’ bleed prior   subarachnoid bleeding.                      specialist review required to confirm
                     to large brain                                                       discharge without further investigation for
                                              No other diagnostic tests performed.
                     (subarachnoid)                                                       atypical headache presentations.
                     haemorrhage three
                     days later.
                     No long-term harm;
                     high-risk event.

 Serious      5      Heparin infusion         Confusion between multiple pumps.           Use of infusion pump ‘smart’ software.         Implemented.
                     (anticoagulant)
                                              Unfamiliarity with volumetric pumps.
                     incorrectly increased
                     to 80ml/hr during
                     minor surgery,
                     causing significant
                     bleeding.

 Sentinel     4A     14 months for an         Booked into incorrect clinic.               Central Referrals Office to ‘colour code’      Completed.
                     urgent (<8 weeks)                                                    clinics as a means of clinic identification.
                                              Administrative procedures for incorrect
                     appointment in the
                                              clinic attendance unclear.                  Written guideline for process for patients
                     eye clinic. Patient                                                                                                 In progress.
                                                                                          presenting to the wrong clinic.
                     now legally blind.       Referral sent to wrong DHB twice.
                                                                                          Regional issue to be discussed with
                                                                                          neighbouring DHBs.                             In progress.

 Unclear      10     Delay in transferring    Inadequate communication and                Electronic register and tracking system        In development.
                     baby from referring      handover.                                   for referrals.
                     DHB. Death possibly
                                              Infectious status conflict with clinical    Referrers advised of thresholds for
                     preventable by earlier                                                                                              In progress.
                                              urgency.                                    escalation.
                     transfer.
                                                                                                                                         No change required.
                                                                                          Review infection control guidelines.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11              14
                                                                                                                                      Auckland District Health Board


Serious or   Event   Description of event                 Review findings                       Recommendations/actions                          Follow-up
 sentinel    code

 Serious      4D     Perforation of uterus    Surgical technique used (Microwave          Scheduled for surgical audit.                  Awaiting review.
                     during gynaecological endometrial ablation technique) caused
                     surgery with bowel       full thickness uterine burn.
                     injury requiring further
                     surgery (rectal
                     resection,
                     hysterectomy and
                     temporary ileostomy).

 Serious      1      Child flown from    Future booking for CT scan had not been          Modification of booking system to require Organisation-wide issue –
                     another DHB for an  cancelled after urgent surgery had been          review and re-confirmation of future      under review.
                     unnecessary CT scan required, making the scan unnecessary.           outpatient bookings after inpatient
                     under general                                                        admissions.
                     anaesthesia.

 Serious      4D     Injury to upper lobe of Misinterpretation of intra-operative test    Surgical audit.                                Complete
                     lung during surgery
                                             Reduced visualisation from minimally-        Re-confirmed the need for absolute
                     (resection of lower
                                             invasive surgical approach                   certainty of anatomy prior to division of
                     lobe), eventually
                                                                                          major structures.
                     requiring complete
                     removal of left lung.

 Sentinel     4B     Four-month delay in     Surgical audit form completed without        Reinforce standards with surgical              Completed.
                     treatment for cancer    histology available.                         registrars.
                                                                                                                                         In process with regional IT
                     as clinical staff
                                             No system to ensure histology results        Mandatory electronic escalation system         provider and individual
                     unaware of
                                             are reviewed after patient discharge.        for unsigned reports.                          services.
                     unexpected findings
                     on histology report.    No mandatory escalation process for          Retrospective sign-off process for all   In process.
                                             unreviewed histology reports.                unaccepted histology reports – automatic
                                                                                          2009 or earlier, manual 2010 onwards.
                                             Important unanticipated abnormal
                                             histology results not highlighted.           Reduce/eliminate paper reports.
                                                                                                                                         May incorporate into e-Lab
                                                                                          Review reporting systems with pathology
                                                                                                                                         development.
                                                                                          and information systems.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11                15
                                                                                                                                       Auckland District Health Board


Serious or   Event   Description of event                  Review findings                          Recommendations/actions                        Follow-up
 sentinel    code

 Sentinel     4D     Aspiration of feed into Nasogastric feeding uncommon on this          Increase awareness in nursing staff            Completed.
                     lungs due to            ward.                                         around best practise with naso-gastric
                     dislodgement of                                                       feeding.
                                             Partial tube removal by patient not
                     naso-gastric tube.
                                             identified.                                   Commencement of bedside handovers.
                     Patient died despite
                                                                                           Naso-gastric Resource Nurse appointed.
                     appropriate
                     treatment.

 Serious      6      Fall causing fractured   Unobserved fall out of bed. Rails in         ADHB Falls Prevention Programme
                     upper arm and            place.
                                                                                               1.    Establish baseline data with consistent identification of falls
                     intracranial (brain)
                                                                                                     with harm for 2010/11 – completed.
                     bleeding.
                                                                                               2.    Develop new metric to track monthly performance – defined
 Serious      6      Fall causing fractured   Fell returning from toilet. Severe                     as falls with major harm per 1000 bed-days – trial monthly
                     ribs and minor           underlying medical conditions. Death                   data now being reported.
                     internal bleeding.       unrelated to injuries.
                                                                                               3.    ‘Gap analysis’ data collection tool to prioritise improvement
                                                                                                      strategies – in progress.
 Serious      6      Fall causing fractured   Child fell in play area of Children’s
                     tooth.                   Emergency Department.                            4.    Develop costing model to assess cost-effectiveness of
                                                                                                     specific fall/harm prevention interventions – in progress.
 Serious      6      Fall causing facial      Unobserved fall from bed with rails while        5. Revise interventional programme on the basis of the above
                     fracture and             awaiting X-ray.                                     data – priority areas now under review.
                     intracranial (brain)
                     bleeding.

 Serious      6      Fall causing fractured   Unwitnessed fall when going to toilet.
                     upper arm.

 Serious      6      Fall causing spinal      Confused patient left ward and fell
                     fractures.               outside hospital.

 Serious      6      Fall causing fractured   Confused. Fell while mobilising without
                     hip.                     assistance.

 Serious      6      Fall causing scalp       Dementia. Fell while mobilising without
                     laceration.              assistance.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11                     16
                                                                                                                               Auckland District Health Board


Serious or   Event   Description of event                 Review findings                         Recommendations/actions                 Follow-up
 sentinel    code

 Serious      6      Fall causing fractured   Fell while mobilising without assistance.
                     hip.

 Serious      6      Fall causing fractured   Unobserved fall from low bed.
                     wrist.

 Serious      6      Fall causing fractured   Unobserved fall while trying to get out of
                     nose.                    bed. Bed rails not in use.

 Serious      6      Fall causing opening     Fall while exercising in gym
                     of surgical wound.       unsupervised.

 Serious      6      Fall causing fractured   Fell while getting up to walker. Did not
                     wrist.                   seek assistance.

 Serious      6      Fall causing             Tripped over mattress on the floor in
                     intracranial (brain)     mental health unit.
                     bleeding.

 Serious      6      Fall causing             Fell while attempting to get out of bed
                     intracranial (brain)     unaided.
                     bleeding.

 Serious      6      Fall causing             Previous hip replacement. Fell while
                     dislocated hip.          attempting low seating position.

 Serious      6      Fall causing facial      No known falls risk. Fell while returning
                     laceration.              to ward from outside hospital.

 Serious      6      Fall causing scalp       Confused. Fell trying to get out of bed
                     laceration.              unassisted.

 Serious      6      Fall causing fractured   Fell while self-mobilising to commode.
                     hip.                     Death from underlying terminal disease.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11      17
                                                                                                                            Auckland District Health Board


Serious or   Event   Description of event                  Review findings                     Recommendations/actions                 Follow-up
 sentinel    code

 Serious      6      Fall causing fractured   High falls risk. Self-mobilised against
                     upper arm.               instruction while staff were attending
                                              another patient.

 Serious      6      Fall causing scalp       Fell while self-mobilising against
                     laceration.              instructions.

 Serious      6      Fall causing facial      Unwitnessed fall in toilet.
                     laceration.

 Serious      6      Fall causing             Fell while being assisted to toilet.
                     intracranial (brain)
                     bleeding.

 Serious      6      Fall causing fractured   High falls risk. Mobilised without
                     sacrum (lower spine).    assistance against instruction.

 Serious      6      Fall causing fractured   Dementia. Fell while mobilising without
                     hip.                     usual assistive aids.

 Serious      6      Fall causing large       Unwitnessed fall in toilet.
                     scalp laceration.

 Serious      6      Fall causing fractured   No known falls risk. New onset urinary
                     hip.                     incontinence. Slipped on wet floor.

 Serious      6      Fall causing fractured   Unsupervised fall when going to toilet.
                     hip.

 Serious      6      Fall causing facial      No known falls risk. Unwitnessed fall.
                     fractures.               May have tripped on bedside table.

 Serious      6      Fall causing fractured   High falls risk. Mobilised without
                     hip.                     assistance against instruction.

 Serious      6      Fall causing fractured   Fainted while being mobilised by
                     ankle.                   physiotherapist.



                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11      18
                                                                                                                       Auckland District Health Board


Serious or   Event   Description of event              Review findings                    Recommendations/actions                 Follow-up
 sentinel    code

 Serious      6      Fall causing facial    Dementia. Mobilised without required
                     laceration.            assistance.




                                                                                   Summary of DHB Serious and Sentinel Event Report 2010/11      19
                                                                                                                          Counties Manukau District Health Board



Counties Manukau District Health Board
www.cmdhb.org.nz

 Serious or   Event     Description of event            Review findings                   Recommendations/actions                           Follow-up
  sentinel    code

  Serious      1      CT scan performed on      Name label mistakenly attached       Review process of storing patient           A Patient Identification Group
                      patient in error.         to another patient’s CT request      identification labels and develop           has been established to review
                                                form.                                interventions to improve safety of          incidents involving
                                                                                     system.                                     misidentification of patients.
                                                                                     Investigate the potential for using         This group is currently working
                                                                                     electronic requests for procedures.         on better systems for storing
                                                                                                                                 and managing labels.
                                                                                                                                 An electronic solution is not
                                                                                                                                 currently feasible, but is likely
                                                                                                                                 to be developed in the next 24
                                                                                                                                 months. The group is
                                                                                                                                 investigating ways of modifying
                                                                                                                                 internal referral processes for
                                                                                                                                 procedures.

  Serious      1      Gastroscopy procedure     Name label mistakenly attached       Review process of storing patient           The Patient Identification
                      was completed on a        to another patient’s form due to:    identification labels and develop           Group is working on a better
                      patient when meant for                                         interventions to improve safety of          system for storing and
                      another patient. The       practice of storing patient        system.                                     managing labels.
                      patient then required a   identification labels for multiple
                                                patients in a single location        Develop and implement a                  A modified World Health
                      second procedure to
                                                                                     Gastroenterology Procedural Checklist.   Organization (WHO) Time Out
                      reinsert a stomach tube    process of writing most                                                     procedures checklist has been
                      (nasojejeunal tube)       referrals at the end of the ward     Develop standard operating procedures
                                                                                                                              implemented in Endoscopy.
                      resulting in a gastric    round                                for Gastroenterology Intervention Suite.
                      perforation.                                                                                            An Endoscopy Quality Group
                                                 absence of a clearly defined                                                has been established to
                                                process, defined roles, use of                                                develop standard operating
                                                ‘Time Out’ in establishing patient                                            procedures.
                                                identity.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11                  20
                                                                                                                       Counties Manukau District Health Board


Serious or   Event     Description of event              Review findings                   Recommendations/actions                        Follow-up
 sentinel    code

 Serious      1      Patient was scheduled for   Absence of a clearly defined         Implement the Time Out before            By the end of July 2011, 1200+
                     a bronchoscopy. Patient     process for checking and             procedure/sedation checklist.            staff had received education on
                     consented for and           confirming patient identity and                                               formal identification of patients
                                                                                      Review of consenting process in the
                     received a gastroscopy in   indications for the procedure with                                            – this was done in conjunction
                                                                                      Endoscopy Unit for patients who have
                     error.                      the patient prior to sedation.                                                with:
                                                                                      English as a second language.
                                                 No clearly defined processes for                                                 updating policy and
                                                 consenting patients who have                                                      procedure
                                                 English as a second language.
                                                                                                                                  roll-out of a standardised
                                                                                                                                   method of face-to-face
                                                                                                                                   engagement with patients
                                                                                                                                   and their whānau
                                                                                                                                  roll-out of the modified
                                                                                                                                   World Health Organization
                                                                                                                                   Time Out procedures
                                                                                                                                   checklist in Endoscopy.

 Serious      4A     Treatment delayed for a     Because the blood test for heart     Multidisciplinary governance group to    A multidisciplinary ‘patient at
                     patient with severe chest   damage (troponin) was negative,      be set up to manage issues relating to   risk’ governance group has
                     pain resulting in the       the severe pain was not              management of the ‘patient at risk’.     been set up.
                     patient sustaining          recognised as being potentially
                                                                                      Ward staff to be up-skilled in           Education and training for
                     significant cardiac         cardiac in origin and care was
                                                                                      management of acute coronary             nursing staff on the ward is
                     damage.                     not escalated.
                                                                                      syndrome and the basic interpretation    ongoing.
                                                 Later electrocardiogram (ECG)        ECG changes.
                                                                                                                             A training session was given to
                                                 signs of an anterior myocardial
                                                                                      Training session for house surgeons on house surgeons by a senior
                                                 infarct (heart attack) were not
                                                                                      anterior myocardial infarct and        medical officer (SMO) and will
                                                 initially recognised by nursing
                                                                                      interpretation of ECGs.                be ongoing as part of the
                                                 and medical staff.
                                                                                                                             annual orientation programme
                                                 The patient was discharged                                                  for the new house surgeons
                                                 home following treatment.                                                   intake.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                  21
                                                                                                                              Counties Manukau District Health Board


Serious or   Event     Description of event               Review findings                      Recommendations/actions                           Follow-up
 sentinel    code

 Serious      4B     Treatment delayed in a       Nursing staff did not recognise        Education and training regarding              Training package around
                     patient with a severe        changes associated with                patients who may have this pathology.         assessing neurological status
                     stroke who deteriorated      deterioration in a patient with a                                                    using the GCS has been
                                                                                         Institute regular formal competency
                     and subsequently died.       severe stroke and did not                                                            developed. This includes an e-
                                                                                         assessments for all nursing staff within
                                                  document observations                                                                module to be completed prior
                                                                                         the stroke ward to ensure maintenance
                                                  overnight. It is unlikely this would                                                 to a face-to-face competency
                                                                                         of clinical skills with regard to using the
                                                  have changed the outcome for                                                         assessment.
                                                                                         Glasgow Coma Scale (GCS) to assess
                                                  this patient.
                                                                                         neurological status.                          This training will be
                                                  Variations in staff understanding                                                    implemented on the ward and
                                                  about when and how often                                                             also included in an
                                                  neurological observations should                                                     organisation-wide orientation
                                                  be undertaken in the                                                                 package.
                                                  neurologically compromised
                                                  patient, including triggers for
                                                  action.

 Serious      4B     After surgery, a patient     There was no mechanism in              Develop a standardised discharge              A standardised discharge
                     was not discharged on a      place to ensure all discharge          checklist and pilot in Surgical Services      checklist was developed and
                     blood thinner (Enoxaparin)   instructions are completed             with a view to possible roll-out across       piloted in Surgical Services. A
                     as planned, and was          and/or checked off prior to the        the organisation.                             working group is being
                     readmitted with a blood      patients discharge.                                                                  developed to consider possible
                                                                                         Review the organisational process of
                     clot (pulmonary saddle                                                                                            roll-out across the division and
                                                  Short-term Enoxaparin                  dispensing Enoxaparin and develop an
                     embolism). No permanent                                                                                           then the organisation.
                                                  prescriptions are not included on      organisation-wide flow chart.
                     harm.
                                                  the discharge medications                                                            A review of the organisational
                                                  prescription as it is customary                                                      process for dispensing
                                                  practice to dispense from the                                                        Enoxaparin was completed.
                                                  patient’s ward.
                                                                                                                                       Flow charts and posters were
                                                                                                                                       developed and placed in all
                                                                                                                                       medication areas. The
                                                                                                                                       pharmacy website was updated
                                                                                                                                       with new information.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11                   22
                                                                                                                           Counties Manukau District Health Board


Serious or   Event     Description of event                Review findings                   Recommendations/actions                        Follow-up
 sentinel    code

 Sentinel     4D     Patient received Warfarin     A pregnancy test was requested       Laboratory report form to be modified     Positive pregnancy test
                     (drug to prevent blood        and checked, but because a           to highlight a positive pregnancy test.   results are now reported
                     clotting) for a clot in the   positive pregnancy test result is                                              in red.
                                                                                        The Haematology Service to develop a
                     leg (deep vein thrombosis     not highlighted in any way it was
                                                                                        policy and procedure detailing who is
                     – DVT) during the first       misread and interpreted as
                                                                                        responsible for sign-off of laboratory
                     trimester of pregnancy,       negative.
                                                                                        results.
                     resulting in harm to the
                                                   The senior medical officer (SMO)
                     baby.
                                                   prescribed Warfarin on the basis
                                                   of a verbal report rather than
                                                   checking the blood results.
                                                   No new encounter number was
                                                   generated for the haematology
                                                   visit. This meant the results were
                                                   sent to the previous service and
                                                   not reviewed.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11             23
                                                                                                                    Counties Manukau District Health Board


Serious or   Event     Description of event           Review findings                  Recommendations/actions                        Follow-up
 sentinel    code

 Serious      5      Patient collapse         Alerts to allergy had not been put Clinicians supported by clinical           Formation of an Allergy and
                     following repeated       in place to prevent subsequent     pharmacists to report all drug allergies   Adverse Reaction Group to
                     exposure to skin         exposures.                         to local and national databases.           address allergy reporting
                     disinfectant                                                                                           issues across the organisation.
                                              Lack of awareness among staff      Implement systems for effective
                     (Chlorhexidine), to
                                              that commonly used swabs           documentation and management of            Clinical pharmacists are taking
                     which the patient
                                              contain Chlorhexidine.             drug allergies and drug adverse            a more active role in allergy
                     had a known and
                                                                                 reactions in the organisation.             and adverse drug reaction
                     documented allergy.
                                                                                                                            reporting.
                                                                                 Raise awareness across the
                                                                                 organisation about the widespread use      Promotional campaign on
                                                                                 of Chlorhexidine in the organisation       reporting and raising
                                                                                 and the potential for patient allergies.   awareness of allergies
                                                                                                                            including presentations to
                                                                                                                            stakeholders is in progress,
                                                                                                                            which will include a poster
                                                                                                                            campaign.
                                                                                                                            Project to increase the
                                                                                                                            functionality of the clinical
                                                                                                                            information system to improve
                                                                                                                            the reporting of allergies and
                                                                                                                            adverse drug reactions is in
                                                                                                                            progress.

 Serious      5      Patient with known       Despite this patient having        See above.                                 See above.
                     allergy was              known allergies to both an
                     administered CT          antibiotic (Vancomycin) and CT
                     Contrast resulting in    Contrast, there was no record of
                     a severe skin            this in the patient information
                     adverse reaction         management system or in the
                     requiring surgical       national databases.
                     intervention.




                                                                                   Summary of DHB Serious and Sentinel Event Report 2010/11                24
                                                                                                                             Counties Manukau District Health Board


Serious or   Event     Description of event                  Review findings                   Recommendations/actions                          Follow-up
 sentinel    code

 Serious      5      Patient with a known and        Failure to report allergy alert on   See above.                                 See above.
                     documented allergy to a         local and national databases.
                     drug (Cyclizine) was
                     administered that drug,
                     resulting in a severe
                     adverse reaction requiring
                     an emergency callout.

 Serious      6      Fall resulting in a fractured   Appropriate interventions to         A Falls Prevention Group was               In the first phase of a
                     ankle.                          mitigate harm for high-risk          established under the ‘Zero Patient        comprehensive falls prevention
                                                     patient not implemented.             Harm’ programme.                           programme, the organisation
                                                                                                                                     has implemented multiple
                                                                                          All falls are investigated to identify
 Serious      6      Fall resulting in a fractured   Appropriate interventions to                                                    strategies to mitigate harm
                                                                                          contributing factors and are referred to
                     hip.                            mitigate harm for high-risk                                                     from falls. These include:
                                                                                          this group to inform falls prevention
                                                     patient not implemented.             strategies.                                   falls risk assessment to be
                                                                                                                                         completed for all patients
 Serious      6      Fall resulting in fractured     Was assessed as high risk but                                                       within six hours of
                     cervical spine and              was for discharge that day.                                                         admission to the ward
                     lacerations to the face.
                                                     Absorbent flooring may have
                                                                                                                                        risk assessment tool
                                                     mitigated harm that occurred
                                                                                                                                         changed to a more
                                                     from this fall.
                                                                                                                                         comprehensive and
                                                                                                                                         internationally validated
 Serious      6      Fall resulting in a fractured   Item required by patient left out                                                   tool that identifies
                     hip.                            of reach. Patient fell out of bed                                                   interventions for every level
                                                     trying to reach it.                                                                 of risk
 Serious      6      Fall resulting in fractured     Patient not reassessed for falls                                                   tailored interventions to be
                     ribs.                           risk after cognitive decline and                                                    put in place for patients at
                                                     was left unattended.                                                                risk of falling
                                                                                                                                        alarm system using
 Serious      6      Fall resulting in facial        Walking frame required by                                                           invisible beams on beds
                     fractures.                      patient left out of reach. Patient                                                  and chairs to be
                                                     mobilised without frame and fell.                                                   implemented in satellite
                                                                                                                                         aged care facilities and
 Serious      6      Fall resulting in a fractured   Not recognised that patient was                                                     adult rehabilitation hospital
                     left shoulder.                  medically unfit to mobilise.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11                 25
                                                                                                                     Counties Manukau District Health Board


Serious or   Event     Description of event                  Review findings                 Recommendations/actions                  Follow-up
 sentinel    code
                                                                                                                                wards for high-risk patients
 Serious      6      Fall resulting in a fractured   Walking frame required by
                     hip.                            patient left out of reach. Patient                                        non-slip socks
                                                     mobilised without frame and fell.
                                                                                                                               absorbent flooring options
                                                                                                                                being investigated for
 Serious      6      Fall resulting in fractured     Falls risk assessment didn’t
                                                                                                                                some areas
                     hip.                            correctly classify patient as high
                                                     risk which meant no                                                       watch criteria developed to
                                                     interventions were put in place to                                         ensure watches are in
                                                     mitigate risk of falling.                                                  place where appropriate.

 Serious      6      Fall resulting in fractured     High-risk patient left unattended.
                     hip.

 Serious      6      Fall resulting in fractured     Falls risk assessment didn’t
                     hip.                            correctly classify patient as high
                                                     risk which meant no
                                                     interventions were put in place to
                                                     mitigate risk of falling.

 Serious      6      Fall resulting in fractured     Falls risk assessment didn’t
                     foot bones (metatarsal).        correctly classify patient as high
                                                     risk which meant no
                                                     interventions were put in place to
                                                     mitigate risk of falling.

 Serious      6      Fall resulting in facial skin   Falls risk was not identified from
                     tear requiring surgery.         either the falls risk assessment
                                                     (not completed) or the clinical
                                                     history (dementia and multiple
                                                     falls). This meant no
                                                     interventions were put in place to
                                                     prevent further falls.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11        26
                                                                                                                     Counties Manukau District Health Board


Serious or   Event     Description of event                Review findings                   Recommendations/actions                  Follow-up
 sentinel    code

 Serious      6      Fall resulting in fractured   No clear criteria in place for
                     left distal femur (thigh      ordering a watch for a patient,
                     bone).                        which meant no ‘watch’ was put
                                                   in place for patient with
                                                   dementia.

 Serious      6      Fall and subsequent death     Falls risk assessment didn’t
                     of a patient who was          correctly classify patient as high
                     terminally ill.               risk which meant no
                                                   interventions were put in place to
                                                   mitigate risk of falling. This
                                                   meant a severely ill patient was
                                                   allowed to mobilise
                                                   independently and fell. It is likely
                                                   the fall may have hastened the
                                                   patient’s death.

 Serious      6      Fall resulting in fractured   Unclear whether high risk of
                     arm (humerus).                falling was included in handover
                                                   between wards when patient
                                                   transferred.
                                                   The addition of the new
                                                   medications for a patient with
                                                   dementia may have contributed
                                                   to the patient falling.

 Serious      6      Fall resulting in a head      The falls risk assessment didn’t
                     injury causing a cerebral     correctly classify the patient as
                     (brain) bleed.                high risk which meant no
                                                   interventions were put in place to
                                                   mitigate risk of falling.
                                                   Patient was on blood thinners
                                                   and required transfer to another
                                                   hospital for surgical drainage.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11      27
                                                                                                                                Counties Manukau District Health Board


Serious or   Event     Description of event                  Review findings                     Recommendations/actions                         Follow-up
 sentinel    code

 Serious      6      Fall resulting in a fractured   The falls risk assessment was
                     arm (humerus).                  not accurately scored and
                                                     therefore appropriate
                                                     interventions not put in place.

 Serious      6      Fall resulting in fractured     Patient request for assistance to
                     ribs.                           remove anti-embolic stockings
                                                     was not acted on and patient
                                                     slipped and fell.

 Serious      6      Fall resulting in fractured     Falls risk assessment incorrectly
                     arm (humerus).                  calculated and no review of risk
                                                     after surgery. No interventions in
                                                     place.

 Serious      6      Fall resulting in fractured     No interventions put in place for
                     wrist.                          a patient assessed as being at
                                                     high risk of falling.

 Serious      6      Fall in Radiology resulting     No requirement for medical
                                                                                            Radiology to consider including triage As a second phase, the Falls
                     in skull fracture.              radiation technologists (MRTs) to
                                                                                                                                   Prevention working group is
                                                                                            questions to assess risk of falls prior to
                                                     assess patient’s risk of falls prior
                                                                                            radiology procedures.                  planning to address falls
                                                     to radiology procedures.
                                                                                                                                   prevention in services such as
                                                     No handover from                       Training package to be developed and
                                                                                                                                   radiology, renal dialysis,
                                                     Emergency Care (EC) to                 implemented for MRTs to reduce risk of
                                                                                                                                   maternity and haematology.
                                                     radiology regarding                    falls.
                                                     patient’s risk of falling.                                                    Future work will include




                                                                                             Summary of DHB Serious and Sentinel Event Report 2010/11              28
                                                                                                                               Counties Manukau District Health Board


Serious or   Event     Description of event                 Review findings                      Recommendations/actions                          Follow-up
 sentinel    code
                                                                                            Review falls risk identification           investigating special cases,
Serious       6      Fall while undergoing an      Patient had been assessed and
                                                                                            procedures in Emergency Care.              such as outliers on different
                     X-ray on the ward             not identified as at high risk of
                                                                                                                                       wards and staff ratios over
                     resulting in a head injury    falling. Fall resulted from a faint
                                                                                                                                       winter.
                     (subdural haemorrhage)        and was likely to have
                     and subsequent death.         contributed to his death.
                                                   Because of the patient’s
                                                   additional conditions, and
                                                   following consultation with his
                                                   family, the decision was made to
                                                   provide palliative care only, and
                                                   the patient subsequently died in
                                                   hospital.

Serious       6      Fall in Radiology resulting   Radiology unaware patient was
                     in a fractured thigh bone     at risk of falling. Patient fell while
                     (femur).                      attempting to stand.

Sentinel      11     Patient on home               Although lines are colour coded          Alert to be sent by Clinical Head to all   Alert has been sent to all renal
                     haemodialysis                 and comply with required safety          renal units in New Zealand advising        units within New Zealand and a
                     inadvertently                 standards, the design of the             them of the risk of inadvertent            Medsafe report submitted.
                     misconnected                  haemodialysis machine allows             misconnection.
                                                                                                                                       A letter was sent to the
                     haemodialysis lines           incorrect connection of lines,
                                                                                            Discussion with the company involved       company requesting
                     causing significant           putting patients at risk.
                                                                                            requesting that connections be             consideration of redesigning
                     blood loss and
                                                   Comprehensive education                  redesigned to prevent future               haemodialysis line
                     death.
                                                   and training in place for                occurrences.                               connections.
                                                   patients on home
                                                                                            Review education process and               Plans are in place to
                                                   haemodialysis, but some
                                                                                            training materials with                    review education and
                                                   revision of the education
                                                                                            organisation education                     training materials for
                                                   process and training
                                                                                            specialists.                               patients.
                                                   materials required to suit
                                                   patient population.




                                                                                             Summary of DHB Serious and Sentinel Event Report 2010/11                  29
                                                                                                                                     Waikato District Health Board



Waikato District Health Board
www.waikatodhb.health.nz/quality

 Serious or   Event    Description of                  Review findings                              Recommendations/actions                          Follow-up
  sentinel    code        event

  Serious      4B     Delay in treatment   Consultant-to-consultant referrals from      Discussion to occur at clinical directors’ forum          Inter-hospital
                      due to transport     all provincial hospital when needing to      regarding consultant-to-consultant referral as this in    project in
                      problems             activate a transport team.                   not a one-business-unit issue. When criteria agreed a     progress.
                      transporting                                                      memo to come out of Chief Medical Advisor (CMA)
                                           There is no 24-hour seven-day a week
                      patient from                                                      office to all provincial hospitals (not Waikato DHB
                                           onsite CT service.
                      regional hospital.                                                rural facilities), advising of new requirement.
                                           There is currently no centrally co-
                                                                                        Undertake a retrospective audit of time of referral and
                                           ordinated transfer role for inter-hospital
                                                                                        time of actual scan for after-hours patients (after
                                           transfers.
                                                                                        4pm) (approx 50 cases over a three-month period).
                                           There is no central air transport service,
                                                                                        Presentation of that data to Management Executive
                                           no contractual requirements re air
                                                                                        Committee and action plan to be developed to
                                           service, no central co-ordination, no
                                                                                        address any issues identified.
                                           budget; plane/helicopter providers are
                                           responsible for their own maintenance.       Implement the inter-hospital transfer project.
                                           This is a rare/complex clinical condition.   No action plan developed as this is a national issue.
                                           There is no clear documented pathway
                                                                                        This risk needs to be added to the organisation risk
                                           within Waikato DHB of how patients with
                                                                                        register/plan.
                                           this condition in a non trauma situation
                                           are managed.                                 There needs to be a standard approach to how
                                                                                        patients with this condition are managed.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11                  30
                                                                                                                                  Waikato District Health Board


Serious or   Event    Description of                 Review findings                            Recommendations/actions                         Follow-up
 sentinel    code        event

 Serious      4B     Delay in patient     Failure by SMO to formally hand over     Clinical Director to write to SMOs outlining SMO
                     treatment due to     care to another SMO (ie, consultant to   responsibilities; ie, that the admitting SMO has
                     lack of SMO          consultant).                             primary responsibility for the patient and that if they
                     oversight. Patient                                            are unable to meet their care obligation they must
                     later died.                                                   formally handover care to another SMO.
                                                                                   Clinical Director to ensure this issue is discussed at
                                                                                   the surgical meeting and that responsibilities and
                                                                                   handover of care are clarified to all SMOs.
                                                                                   The Clinical Director to ensure that all surgical
                                                                                   registrars are advised that should they have
                                                                                   concerns and the SMO is not available, they are to
                                                                                   escalate to the Clinical Director or Clinical Unit
                                                                                   Leader.
                                                                                   A copy of this documentation to be included in the
                                                                                   Registrar service orientation documentation.

 Serious      4G     Delay in treatment   Review under way.                        Issues identified will be addressed through the           Ongoing.
                     due to transport                                              Midland region inter hospital project currently in
                                          Referred to Coroner.
                     problems                                                      progress
                     transferring
                     patient from
                     regional hospital.
                     Patient died in
                     theatre.

 Serious      4G     Delays in            Review under way
                     management of
                     trauma patient’s
                     care. Patient died
                     10 days later.




                                                                                    Summary of DHB Serious and Sentinel Event Report 2010/11                31
                                                                                                                                     Waikato District Health Board


Serious or   Event    Description of                 Review findings                              Recommendations/actions                          Follow-up
 sentinel    code        event

 Serious      4A     Delay in diagnosis   The patient had a cancer type that was      Share learnings of the review with medical staff.
                     of cancer.           rare and difficult to diagnose. Incidence
                                                                                      A key person is needed to case manage a patient
                                          is reported to be an incidence of 1-2 per
                                                                                      identified as a complex case.
                                          million.
                                                                                      Identify key roles within the service to undertake the
                                          There were fragmented pieces of
                                                                                      case management function.
                                          information: the operation note of 2007,
                                          histology of 2007 (reported in 2008), and   Short-term solution:
                                          the patient’s symptoms of 2009. These
                                                                                      Purchase a dedicated printer or sorting printer for the
                                          were not put together to get a complete
                                                                                      inpatient CT and the outpatient CT machine so faxing
                                          clinical picture for the patient until
                                                                                      is sorted to a separate area from printing.
                                          November 2009.
                                                                                      Review the process for managing/processing referral
                                          The CT request form of Nov 2009 was
                                          lost due to a paper-based referral          forms received into the department. This includes:
                                          system with multiple entry points which             introducing electronic order entry
                                          caused a further three-month delay in
                                          diagnosis.                                          ability of teams to view wait times
                                                                                              how faxed referrals are received.
                                                                                      Discussion to take place at Community Laboratory
                                                                                      Governance Forum re GPs receiving results
                                                                                      electronically.
                                                                                      Undertake a review of current discharge checking
                                                                                      processes within each area and advise any changes
                                                                                      required.

 Serious      4D     During a check       Review under way.
                     procedure
                                          Referred to Coroner.
                     involving a
                     pacemaker, the
                     device was turned
                     off accidentally.
                     Patient
                     deteriorated and
                     died.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                32
                                                                                                                                      Waikato District Health Board


Serious or   Event    Description of                  Review findings                               Recommendations/actions                         Follow-up
 sentinel    code        event

 Serious      4G     Patient pulled out   Critically ill, confused, patient bled to    Review how critically unwell, elderly confused
                     intravenous line,    death because his femoral central            patients are managed in acute settings – this action
                     which led to         venous line was pulled out. The patient      included in the Delirium project.
                     death.               had a history of pulling out lines and the
                                                                                       Review handover and transfer process whereby
                                          patient required restraint.
                                                                                       patients transferred from areas with high nurse:
                                          Inadequate assessment of the risks for       patient ratio to areas with lower nurse: patient ratio.
                                          this patient was undertaken at the
                                                                                       Formalise the handover process between health
                                          receiving ward, and inadequate
                                                                                       professionals as part of the Hospital at Night project.
                                          documented plan of care for the
                                          management of the patient’s confusion,       Random audit by two Nurse/Midwife Directorate
                                          history of pulling lines and presence of a   members to critically analyse a set of patient records
                                          central venous line.                         and provide feedback to the charge nurse where this
                                                                                       is inadequate or incomplete.
                                          Death referred to Coroner who decided
                                          not to investigate further.

 Serious      4B     Senior doctor        The practice of not rostering specialist     Changes made to roster to ensure specialty medical         Completed.
                     responsible for      medical staff on the night duties resulted   staff are on call.
                     patient was not      in consultant not being called to review
                     informed of          patient.
                     deteriorating
                     patient condition.
                     Patient died later
                     in day.

 Serious      4B     Failure to           Misinterpretation of patient’s clinical      Document for management of trauma cases to be
                     diagnose/            signs and symptoms led to patient being      updated in required format.
                     recognise            clinically managed as a stable rather
                                                                                       Implementation plan to include          education    and
                     unstable patient.    than an unstable patient.
                                                                                       ongoing education and orientation.
                                                                                       To re-assess ED medical staff number against
                                                                                       expected norm for other equivalent EDs.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11                33
                                                                                                                                     Waikato District Health Board


Serious or   Event    Description of                    Review findings                             Recommendations/actions                        Follow-up
 sentinel    code        event

 Serious      10     Delay in treatment     Review under way.                           [HQSC comment – subsequently advised by DHB
                     due to transport                                                   after SSE report went to printing that case not an
                     problems                                                           SSE]
                     transporting
                     patient from
                     regional hospital.
                     Patient died.

 Serious      4G     Patient died on        Review under way.
                     ward shortly after
                     admission from
                     ED.

 Serious      4A     Delay in diagnosis     Review under way.
                     of cancer due to
                     failure to follow up
                     results. Patient
                     has subsequently
                     died.

 Serious      4D     Patient suffered       Review under way.
                     complications
                     during surgery
                     and required
                     further surgery.

 Serious      4B     Communication          Department staff unaware of the             Department staff will contact requesting clinician
                     breakdown              requirement to contact the requesting       directly to advise of significant change.
                     between services       clinician if a significant change to a
                                                                                        Develop a process for recording this communication
                     resulted in            result or diagnosis is made.
                                                                                        in the clinical record.
                     delayed treatment
                                            Department staff currently have no
                     for patient. Patient                                               Department to adjust format of report sent so that if
                                            process of recording these notifications/
                     has since had                                                      further work is being done to confirm diagnosis this
                                            conversations in the patient’s clinical
                     appropriate                                                        will be clearly documented in report.
                                            record.
                     management and
                     treatment.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11              34
                                                                                                                                Waikato District Health Board


Serious or   Event    Description of                 Review findings                           Recommendations/actions                        Follow-up
 sentinel    code        event

 Serious      4B     Delays in referral   Lack of clear processes in place to     Process to be developed for return of care of patients
                     and treatment of     manage these high-risk patients.        to Diabetes Podiatry service.
                     patient. Patient
                                                                                  [Waikato DHB subsequently stated that, following
                     developed
                                                                                  further review, this case was not a serious event.
                     problems and
                                                                                  However, this advice was received after the SSE
                     required toe
                                                                                  report was completed, and this case is included in
                     amputation.
                                                                                  the data within the main report.]

 Serious      4B     Delay/failure to     The process for checking and ensuring   Share learning about this incident with all clinical and
                     treat abnormality    patient’s details are correct was not   administrative staff, eg, at staff meeting.
                     leading to patient   carried out.
                                                                                  Emphasise the practice of checking patient details
                     developing
                                                                                  and updating of patient label and information on
                     cervical cancer.
                                                                                  clinical records during each visit to ensure
                                                                                  information current and correct.
                                                                                  Mandatory use of electronic system for such details.
                                                                                  Check and refresh patient details during each visit to
                                                                                  ensure information current and correct.
                                                                                  Audit of this compliance to take place.




                                                                                  Summary of DHB Serious and Sentinel Event Report 2010/11                35
                                                                                                                                 Waikato District Health Board


Serious or   Event    Description of                  Review findings                            Recommendations/actions                       Follow-up
 sentinel    code        event

 Serious      4B     Core midwife did     Documentation of the outcome of the       Develop a package that clearly identifies the
                     not see that she     assessment, interpretation of the fetal   requirements when assessing an LMC’s patient.
                     had full             monitoring and nature of the discussion   This will be given to each core midwife who will sign
                     responsibility for   with the LMC was not of the required      to identify they have read, understood and will
                     the patient in the   standard.                                 comply.
                     absence of the
                                          Internal perinatal review revealed that   Re-launch fetal monitoring protocol with staff.
                     Lead Maternity
                                          fetal compromise occurred within last
                     Carer (LMC). This                                              Develop a telephone record to capture clinical data
                                          weeks of baby’s life.
                     led to a                                                       when requested to assess an independent midwife’s
                     communication                                                  patient.
                     issue between
                     core and
                     independent
                     midwife regarding
                     fetal monitoring
                     outcome.
                     Baby was born
                     dead two days
                     later.

 Serious      4B     Delay in             Independent midwife did not recognise     Introduce updated emergency flip chart, strategically
                     transferring         the significance of the bleed and         placed.
                     mother with post-    escalation process was delayed.
                                                                                    Education for nursing staff on emergency
                     partum bleed from
                                                                                    management.
                     rural maternity
                     unit to tertiary
                     unit. Both mother
                     and baby
                     recovered well.




                                                                                     Summary of DHB Serious and Sentinel Event Report 2010/11              36
                                                                                                                                  Waikato District Health Board


Serious or   Event    Description of                  Review findings                             Recommendations/actions                        Follow-up
 sentinel    code        event

 Serious      4B     Delay in treatment   The major root cause of this incident is    Ongoing vigilance by screening staff members when        Completed.
                     of woman with        the database having a reporting failure.    checking reports to ensure there are no other
                     breast cancer.                                                   anomalies with other invitational processes.
                                                                                      As a result of identifying these issues, the data
                                                                                      manager has developed a new local Access failsafe
                                                                                      report to prevent and mitigate the risk of similar
                                                                                      incidents occurring/reoccurring in the future.

 Serious      4G     Patient suffered     Patient was discharged to an area           Discharge process was reviewed and education             Completed.
                     complications as     where staff were unfamiliar with            provided to staff on how to use this equipment safely.
                     a result of          equipment being used on patient.
                     treatment and
                     required further
                     surgery.

 Serious      4G     Delay in             Review in progress.
                     recognition and
                     management of
                     patient who
                     presented to ED
                     with stroke.

 Serious      6      Patient fell and     Incomplete assessment since admission       Share learning of this event with nursing and medical
                     fractured hip.       led to inadequate care planning and         staff including implication of practice about
                                          management of the specific needs of an      management of confused patients.
                                          elderly patient with physical limitations
                                                                                      Implement the falls management practices to area.
                                          and co-morbidity in an unfamiliar
                                          environment of a hospital.

 Serious      6      Patient fell and     Incomplete assessment on admission          Share learning of this event with nursing and medical
                     sustained a head     led to inadequate care planning and         staff including implication of practice about
                     injury. Patient      management.                                 management of the specific needs of a confused
                     died five days                                                   elderly patient with physical limitations and co-
                                          Referred to Coroner.
                     later from injury.                                               morbidity in an unfamiliar environment of a hospital.
                                                                                      Implement the falls management practices to area.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11               37
                                                                                                                                       Waikato District Health Board


Serious or   Event    Description of                    Review findings                                 Recommendations/actions                      Follow-up
 sentinel    code        event

 Serious      6      Patient fell and       Review under way.
                     fractured hip.
                     Patient’s condition
                     deteriorated, and
                     the patient died
                     five weeks later.

 Serious      6      Patient fell and       Patient mobilised independently without      Share learning of this event with nursing and medical     Ongoing
                     fractured hip.         supervision.                                 staff including implication of practice about
                     Surgery required                                                    management of the specific needs of a confused
                     and patient                                                         elderly patient with physical limitations and co-
                     deteriorated                                                        morbidity in an unfamiliar environment of a hospital.
                     following surgery
                                                                                         Implement the falls management practices to area
                     and died.                                                                                                                     Completed

 Serious      6      Patient fell whilst    Patient while in a confused and              As a result of this incident the following actions were
                     mobilising             disorientated state pushed a table aside,    taken:
                     independently.         mobilised independently and fell.
                     Condition                                                                all tables fitted with brakes
                                                                                                                                                   Completed.
                     deteriorated and                                                         ward continues to trial and evaluate different
                     patient died                                                              equipment resources to minimise falls, including
                                                                                               current use of exit alarms and pressure
                                                                                               mats/cushion.
                                                                                              falls project completed and new risk                Completed.
                                                                                               assessments and education in place for staff.

 Serious      6      Patient fell and hit   The patient was not sufficiently stable on       Falls project completed and new risk assessments      Completed.
                     head. Condition        feet, due to clinical condition                  and education in place for staff.
                     deteriorated
                                                                                             Audits completed to ensure compliance with falls
                     following fall and                                                                                                            Completed.
                                                                                             assessment requirements.
                     patient died




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11               38
                                                                                                                                 Waikato District Health Board


Serious or   Event    Description of                  Review findings                             Recommendations/actions                      Follow-up
 sentinel    code        event

 Serious      6      Patient fell and     No root causes found.                       Other learning needs identified:
                     fractured hip.
                                                                                      Review staff knowledge of care planning process and
                     Required surgery.
                                                                                      timely/accurate completion of documentation –
                     Condition
                                                                                      including the process of handover/completion of
                     deteriorated after
                                                                                      information between shifts.
                     surgery, and
                     patient died.

 Serious      6      Patient fell from    All appropriate actions pre and post fall   Review supervision of compromised patients whilst in
                     bed and              were taken.                                 bed.
                     sustained a head
                     injury and died.

 Serious      6      Patient fell and     Patient fell whilst standing from           Falls project completed and new risk assessments       Completed.
                     sustained            commode.                                    and education in place for staff.
                     fractured
                     shoulder. Patient
                     later died from
                     unrelated events.

 Serious      6      Patient fell and     Patient was not compliant with medical      Medical team to discuss with Mental Health team as     Completed.
                     fractured ankle.     treatment, due to other medical             to future management of patient in ways that will      Agreed plans in
                                          conditions.                                 allow required medical management.                     place for
                                                                                                                                             ongoing care.

 Serious      6      Patient fell and     Unpreventable fall. Review identified       No recommendations.
                     fractured hip        that all appropriate actions pre and post
                     requiring surgical   fall were taken.
                     repair.

 Serious      6      Patient fell         Inadequate     care    planning    and      Falls project completed and new risk assessments
                     mobilising and       management of specific needs of a           and education in place for staff.
                     fractured            confused elderly patient with physical
                     shoulder. No         limitations and other medical problems
                     surgical             in an unfamiliar environment of a
                     intervention         hospital.
                     required.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11             39
                                                                                                                                      Waikato District Health Board


Serious or   Event    Description of                  Review findings                               Recommendations/actions                         Follow-up
 sentinel    code        event

 Serious      6      Patient fell and     Patient with confusion mobilised and fell.   Falls project completed and new risk assessments          Completed.
                     fractured hip.                                                    and education in place for staff.
                     Surgical repair
                     required.

 Serious      6      Patient fell and     Patient with limited mobility mobilised      Falls project completed and new risk assessments          Completed.
                     required surgical    and fell.                                    and education in place for staff.
                     repair of
                     lacerations
                     sustained in fall.

 Serious      6      Patient fell and     Patient lost balance when closing the        Patients will be supervised with their mobility for the   Completed.
                     sustained            bathroom door.                               first 48 hours of admission regardless of level of
                     fractured hip.                                                    independence.

 Serious      6      Patient fell and     Patient fell earlier in day and no           Falls project completed and new risk assessments          Completed.
                     fractured wrist.     corrective actions taken to minimise,        and education in place for staff.
                                          thus patient fell again later.

 Serious      6      Patient fell and     Patient assessed as requiring                Falls project completed and new risk assessments          Completed.
                     fractured hip,       assistance mobilising walked alone and       and education in place for staff.
                     which required       fell.
                     surgical repair.

 Serious      6      Patient fell and     Patient with fluctuating confusion and       Patients who are able shall have meals in the dining      Completed.
                     sustained head       decreased mobility attempted to              room with one staff member present at all times.
                     injury (sub          mobilise unaided. Patient was known to
                                                                                       Rapid nursing rounds are conducted Mon-Fri and
                     arachnoid            be high risk for falling and was on                                                                    Completed.
                                                                                       identify that fall risk assessment is carried out per
                     haemorrhage).        increased watch.
                                                                                       procedure.

 Serious      6      Patient fell and     Review in progress.
                     fractured hip,
                     requiring surgical
                     repair.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11                40
                                                                                                                                      Waikato District Health Board


Serious or   Event    Description of                  Review findings                               Recommendations/actions                         Follow-up
 sentinel    code        event

 Serious      6      Patient fell         Patient stood up from chair and fell.        Increased supervision for patient.                        Completed.
                     resulting in her
                                                                                       Use of lap belt identified as appropriate for this        Completed.
                     sustaining a
                                                                                       patient.
                     fractured wrist.

 Serious      6      Patient fell and     Patient with history of falls mobilised      Falls project completed and new risk assessments          Completed.
                     sustained            without supervision.                         and education in place for staff.
                     fractured skull.

 Serious      6      Patient fell and     Patient with history of falls mobilised      Falls project completed and new risk assessments          Completed
                     sustained head       without supervision.                         and education in place for staff
                     injury.

 Serious      6      Patient fell and     Patient mobilised independently without      Falls project completed and new risk assessments          Completed.
                     dislocated pelvis    supervision.                                 and education in place for staff.
                     bone.


 Serious      6      Patient fell and     Patient had medical condition that likely    Introduction of escalation flow chart to expedite         Completed.
                     fractured            contributed to fall.                         transfers to medical wards and consistency of
                     shoulder.                                                         information used to assess requirement for general
                                                                                       hospital admission.

 Serious      11     Patient’s cardiac    Review concluded that no issue with          No root causes found.                                     Completed
                     arrest not noticed   alarms. Active resuscitation was initiated
                     as alarm did not     within seconds of arrest being noticed.
                     activate in
                                          Referred to Coroner.
                     theatre. Patient
                     died later in ICU
                     from other
                     causes.

 Serious      12     Elective             Review concluded no issues with care         Consideration is given to extending the hospital flu      Completed.
                     admission to         provided.                                    vaccination programme to offer the flu vaccine to
                     hospital. Patient                                                 high-risk patient groups.
                     developed flu in
                     hospital and died.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11                41
                                                                                                                                    Waikato District Health Board


Serious or   Event    Description of                  Review findings                              Recommendations/actions                         Follow-up
 sentinel    code        event

 Sentinel     1      Patient had          The patient identity was not verified by    To develop a policy on patient identification. Policy to
                     procedure (PICC      two members of staff to ensure correct      have implementation plan agreed as part of process.
                     Line –               patient was transferred to radiology.
                                                                                      To develop a patient verification handover process –
                     peripherally
                                                                                      this process to include patient not to be transferred
                     inserted central
                                                                                      until process is completed. Process to include phone
                     catheter –
                                                                                      verification checks.
                     inserted) that was
                     meant for another                                                To implement the WHO Surgical Safety Checklist for
                     patient.                                                         Radiology Interventions Only process.                      Completed

 Sentinel     3      Patient had          Patient’s procedure did not stop when       Review implementation process of the Waikato DHB
                     retained swab        incorrect count was notified to the team.   policy: Surgical Count for Swabs, Sharps and
                     following cardiac                                                Instruments.
                     procedure.
                                                                                      Discussion to take place regarding implementing a
                     Required
                                                                                      ‘Time Out/Stop’ command when incomplete count is
                     additional
                                                                                      notified. If agreed, this action to be added to Surgical
                     procedure to
                                                                                      Count for Swabs Sharps and Instruments policy.
                     remove swab.
                                                                                      Implement the WHO Surgical Safety Checklist in
                                                                                      department.
                                                                                      The operating surgeon should also verbally
                                                                                      acknowledge they have heard the scrub practitioner
                                                                                      (Rationale 6).




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                42
                                                                                                                                    Waikato District Health Board


Serious or   Event    Description of                   Review findings                             Recommendations/actions                        Follow-up
 sentinel    code        event

 Sentinel     1      Surgical              Ineffective quality control processes      Review laboratory process/work flow (in consultation
                     procedure             being in place/implemented and             with Waikato DHB process specialist).
                     performed on          environmental issues led to biopsy
                                                                                      Review the current quality monitoring and reporting
                     wrong patient due     tissue belonging to Patient B being
                                                                                      systems within laboratory and implement any
                     to two patients’      placed in Patient A cassette during
                                                                                      recommendations.
                     biopsy samples        laboratory process.
                     being mixed up,                                                  Initiate creation of a regional networking quality
                                           This resulted in patient having surgical
                     and incorrect                                                    model (with a focus on learning/sharing of best
                                           procedure meant for another patient.
                     diagnoses for                                                    practice) for this laboratory.
                     both patients
                                                                                      Revise/produce procedure documentation regarding
                     involved.
                                                                                      independent double checks on biopsy specimens.
                                                                                      Review practice of processing like specimens (eg,
                                                                                      breast) through laboratory.
                                                                                      Review options for technical and managerial
                                                                                      leadership structures in this laboratory.

 Serious      4A     Two patients’         As above.                                  As above.
                     biopsy samples
                     were mixed up
                     resulting in
                     incorrect
                     diagnoses for
                     both patients
                     involved.

 Serious      11     Patient assaulted     Review completed.                          Scheduled for panel 2012.
                     a third person
                     whilst being
                     transported to
                     hospital by family.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11               43
                                                                                                                                 Waikato District Health Board


Serious or   Event    Description of                 Review findings                            Recommendations/actions                         Follow-up
 sentinel    code        event

 Serious      11     Patient attempted    Observation levels were not clearly       Clarity on observation procedure given to all ward       Completed
                     self-harm and        communicated or promptly enacted.         staff and confirmation of responsibility for handover
                                                                                                                                             March 2011
                     sustained minor                                                between shifts.
                                          Service user was not sighted by morning
                     injuries.                                                                                                               April 2011.
                                          staff at commencement of shift.           Handover procedure has been amended to including
                                                                                    the requirement for staff to sight all service users
                                          New RN not aware RNs can increase
                                                                                    immediately following handover.
                                          level of observation without medical
                                          officer approval if risk identified.      All new nurses to have identified preceptors and
                                                                                    training to be provided to increase number of
                                                                                    available preceptors. Training continues through         Ongoing.
                                                                                    2011 and preceptorship and available preceptors are
                                                                                    monitored via the Clinical Nurse Director and Clinical
                                                                                    Governance Forum.

 Serious      11     Self-harm            The immediate management and              Review the Levels of observation procedure to            Ongoing
                     resulting in life-   communication of identified escalating    include: The communication and management plan
                     threatening          risk directly following assessment, was   process between staff, directly following assessment
                     injuries.            not adequate..                            indicating increased risk.




                                                                                     Summary of DHB Serious and Sentinel Event Report 2010/11               44
                                                                                                                                       Bay of Plenty District Health Board



Bay of Plenty District Health Board
www.bopdhb.govt.nz

 Serious or   Event   Description of event                  Review findings                       Recommendations/actions                           Follow-up
  sentinel    code

  Serious      3      Four months after          Investigation difficult as staff recall of   Improve team culture – the                 Subject to ongoing monitoring.
                      surgery, retained swab     event poor.                                  productive operating theatre and
                      identified during X-ray.                                                team steps have been implemented
                                                 Systems in place are sufficient.
                                                                                              in theatre.
                                                 Communication within teams to be
                                                 enhanced.

  Serious      4D     Blood stream infection     Reviewed by the infection control            Issues identified will be addressed        Completed.
                      resulting from an IV       team. On earlier discharge when IV           with the implementation of the audit
                      line requiring long-term   cannula removed it was noted to be           recommendations.
                      antibiotics and            red. Readmitted with severe sepsis.
                      prolonged inpatient        The findings were consistent with
                      stay.                      recent IV audit.

  Sentinel     4C     Failure to recognise       Lack of a standardised process of            Standardised handover process is           SBARR (model for effective
                      and act on                 handover between departments                 implemented in all clinical contexts.      information transfer)
                      deteriorating condition    contributed to a loss of continuity with                                                implemented.
                                                                                              Consideration should be given to
                      resulting in death.        plan of care.
                                                                                              how to ensure that it is understood
                                                 Failure to repeat observations               that MEWS is the explicit trigger tool
                                                 following abnormalities resulted in          for clinical communication and
                                                 the MEWS (Modified Early Warning             escalation.
                                                 Score) not being adequately
                                                 assessed or interpreted, causing a
                                                 delay in response.

  Serious      1      Appendix removed           Abnormal position of fallopian tube.         Ongoing education for surgeons to          Lessons learnt shared.
                      subsequently found to      Anatomy distorted by inflammatory            include identifying and confirming
                      be an ovary.               process.                                     anatomy where anatomy is unusual.
                      Error not noted until
                      pathology results
                      received.



                                                                                              Summary of DHB Serious and Sentinel Event Report 2010/11                45
                                                                                                                                     Bay of Plenty District Health Board


Serious or   Event   Description of event                  Review findings                      Recommendations/actions                           Follow-up
 sentinel    code

 Serious      9      Unwitnessed assault        Risk assessment and management              Nil recommendations made.                  Referred to Police.
                     on an inpatient by co      plan appropriate.
                     patient. Sustained
                     multiple injuries
                     resulting in permanent
                     disability.

 Serious      4D     IV drug leaked into        IV cannula insertion difficult as           Feedback to nursing staff on               Completed.
                     tissue, requiring          patient having a fit. IV protocol           Phenytoin infusion (drug to treat fit)
                     surgery.                   including flushing line was followed        and selection of IV insertion site.
                                                and the line was deemed patent. As
                                                the patient was suffering a fit, the line
                                                was secured with a bandage, thus
                                                unable to observe.
                                                Two hours later, the IV site was
                                                checked and leak was discovered.

 Serious      6      Inpatient fall resulting   Elderly patient who required                BOPDHB Patient Safety Programme has three significant organisation-
                     in fractured shoulder.     assistance to mobilise got out of bed       wide projects under way including Safe Mobilisation – reducing harm
                                                to go to bathroom, without calling for      from inpatient falls.
                                                assistance.
                                                                                            Literature reviewed shows that no one strategy works.
 Sentinel     6      Inpatient fall resulting   Appropriate assessment made but             Falls with harm for BOPDHB have been analysed and strategies to
                     in subsequent death.       still fell. The apparent cause of the       address the key causes of falls have been identified and the following
                                                fall was multi-factorial, and not           plan is being implemented.
                                                necessarily attributed to a single
                                                                                            Medical ward identified as pilot site:
                                                cause.
                                                                                               HCA/RN (Health Care Assistant/Registered Nurse) rounding
 Sentinel     6      Inpatient fall resulting   The fall was not the root cause of the
                                                                                               ward tidies
                     in fractured hip and       death.
                     subsequent death.
                                                No formal falls risk assessment                bedside ‘flip chart’ developed – mobility tool
                                                undertaken. Reporting requirements             patient assessment (based of LITE assessment tool) assessment/
                                                not met.




                                                                                            Summary of DHB Serious and Sentinel Event Report 2010/11                46
                                                                                                                                Bay of Plenty District Health Board


Serious or   Event   Description of event                  Review findings                     Recommendations/actions                        Follow-up
 sentinel    code
                                                                                               care plan tool developed.
 Serious      6      Inpatient fall resulting   Unwitnessed fall. Patient assessed
                     in fractured hip.          as requiring a walking frame to            Whole-of-organisation education day planned promoting ‘safe
                                                mobilise moved from a chair back to        mobilisation’.
                                                bed without it.
                                                                                           A review of ‘low, low’ beds was found to make a difference. Plan in
                                                                                           place to increase access to these.
 Serious      6      Inpatient fall resulting   Unwitnessed fall. Identified as high
                     in fractured hip.          falls risk. Was able to mobilise with
                                                frame and assistance of one.

 Serious      6      Inpatient fall resulting   Unwitnessed fall. Patient assessed
                     in fractured hip.          as high falls risk, ‘desperate’ to go to
                                                the toilet got up without assistance.
                                                Impression: collapse secondary to
                                                effects of night sedation.

 Serious      6      Inpatient fall resulting   Elderly patient with dementia
                     in fractured pelvis (no    observed mobilising with walking
                     surgery).                  frame ‘just fell’.

 Serious      6      Inpatient fall resulting   Unwitnessed fall. Elderly patient
                     in fractured pelvis (no    assessed as requiring supervision
                     surgery).                  with all mobility got up to go to the
                                                toilet without calling for assistance.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11              47
                                                                                                                                      Lakes District Health Board



Lakes District Health Board
www.lakesdhb.govt.nz

 Serious or   Event    Description of event                 Review findings                  Recommendations/actions                         Follow-up
  sentinel    code

  Serious      6      Patient fall resulting in    Falls Risk Assessment not             Discussions with ward staff regarding    Bi-monthly Falls Committee
                      fractured hip and            completed on admission. History       Falls Risk Assessments being             Meetings.
                      surgery.                     indicated falls risk.                 completed on admission.
                                                                                                                                  DHB participating in National
                                                                                         DHB has implemented a Falls              Working Party on Falls
                                                                                         Committee which is preparing an          Prevention. DHB will implement
                                                                                         annual plan and identifying a review     national guidelines when
                                                                                         process of falls strategies.             agreed.
                                                                                         Feedback regarding falls strategies      Units implementing their own
                                                                                         to be given to the governance groups     local falls initiatives and
                                                                                         of all services.                         undertaking regular falls audits.

  Serious      4B     Anticoagulants               CHADS scoring (Clinical prediction    DHB will review CHADS scoring            CHADS scoring is in the policy.
                      discontinued when they       tool for determining the risk of      guideline as it impacts across the       Nurse-led specialists are in
                      were clinically indicated.   stroke) is not routinely undertaken   service.                                 position for preoperative clinics.
                                                   as part of DHB guidelines as                                                   Colorectal nurse position is not
                      Patient suffered a stroke                                          Surgical Services is currently
                                                   bridging therapy in the pre-                                                   yet funded.
                      on day of procedure                                                reviewing the preoperative care
                                                   operative care process.
                      requiring longer hospital                                          documentation and this has
                      stay and ongoing                                                   highlighted the need for a more co-
                      rehabilitation.                                                    ordinated approach to management
                                                                                         of anticoagulation.
                                                                                         Surgical Services is developing a
                                                                                         proposal for a colorectal nurse
                                                                                         specialist position. Such a position
                                                                                         will aim to provide a more
                                                                                         comprehensive care programme for
                                                                                         all patients and reduce the likelihood
                                                                                         of such events in the future.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11                48
                                                                                                                                 Lakes District Health Board


Serious or   Event    Description of event                 Review findings                  Recommendations/actions                   Follow-up
 sentinel    code

 Serious      6      Patient fall resulting in    Clinical File Review completed.       No further action.
                     fracture of bone in face
                                                  Family meeting determined fall was
                     (maxillary sinus).
                                                  a result of a health professional’s
                                                  actions not a process failure.

 Serious      5      Morphine over-               Poor prescribing practice.            The Intensive Care Head of
                     prescribed and               Prescribing according to protocol,    Department has issued a
                     administered for pleuritic   however Lakes DHB did not have a      memorandum to all doctors around
                     (chest) pain.                morphine titrate protocol.            the appropriate prescription of
                                                                                        morphine (doses in particular) for the
                     Patient went into            Not all nurses within the secondary
                                                                                        general wards as opposed to the ICU
                     respiratory arrest and       service hospital had the expertise
                                                                                        setting.
                     required intubation. A       to provide narcotics on titrate
                     full recovery was made.      protocol.                             Development of an organisation-wide
                                                                                        protocol for intravenous opioids for
                                                                                        acute pain, identifying the level of
                                                                                        expertise required to administration
                                                                                        it. This includes a flow chart for
                                                                                        decision-making.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11        49
                                                                                                                                         Tairawhiti District Health Board



Tairawhiti District Health Board
www.tdh.org.nz

Tairawhiti DHB has adopted the Severity Assessment Code (SAC) rating terminology in accordance with the draft national policy on reportable events. SAC1 and
SAC2 events are broadly comparable, respectively, with ‘Sentinel’ and ‘Serious’ events.

The SSE report stated that Tairawhiti had six SSEs. Following review, one of these cases was the suicide of a community mental health and addiction services
patient in the community, so should not have been included in the overall numbers.

 Serious       Event       Description of event         Review findings                     Recommendations/actions                                Follow-up
   or          code
 sentinel

 Serious         6        Fall causing injury to   Inconsistent communication     Revise the handover process between inpatient          Vacancy filled.
                          eye and subsequent       processes for patients         wards and the rehab unit and consider handover
                                                                                                                                         Falls policy reviewed and
                          loss of vision in that   attending the Day of           sheet.
                                                                                                                                         implemented, including:
                          eye.                     Rehabilitation Unit (DRU).
                                                                                  Visual means of identifying patients at risk of
                                                   Clinical notes did not         falling in line with new Falls Policy.                    new falls risk form and
                                                   accompany patient to the                                                                  identification stickers as
                                                                                  Clinical notes to accompany patients to the                an easy communication
                                                   DRU.
                                                                                  rehab unit.                                                method to identify
                                                   Out-dated falls policy and                                                                patients at risk of falling
                                                                                  Implement revised Falls Policy.
                                                   hence varying
                                                   understanding of falls risk.   Training regarding falls risk and prevention              handover between ward 9
                                                                                  provided to all levels of staff who care for at risk       and DRU standardised
                                                   DRU nurse vacancy.
                                                                                  patients, at orientation and updates thereafter.          clinical notes accompany
                                                                                                                                             patients attending DRU.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11                    50
                                                                                                                                 Tairawhiti District Health Board


Serious    Event   Description of event         Review findings                      Recommendations/actions                               Follow-up
  or       code
sentinel

Serious     4F     Injury sustained while   No child/youth inpatient       Develop and implement policy relating to              Reviewed pathway for
                   patient awaiting         mental health facility         transfer of patients to inpatient facility.           management of patients
                   admission to             available locally.                                                                   requiring transfer out of
                                                                           Improve communication between Child and
                   child/youth mental                                                                                            district. Work in progress.
                                            Challenges in caring for       Adolescent Mental Health Service (CAMHS), the
                   health unit.
                                            children suffering mental      paediatric ward and adult in-patient ward to
                                            health problems between        better manage such situations.
                                            a safe environment and
                                                                           Funding for better support in the community
                                            what is in the best interest
                                                                           where inpatient care is not in the best interest of
                                            of the child.
                                                                           the patient.
                                                                           Mental health staff to provide care to patients in
                                                                           their own home.
                                                                           Written information given to family to support
                                                                           decision-making.
                                                                           CAMHS implement a practice that addresses
                                                                           leave provisions for patients detained under the
                                                                           Mental Health Compulsory Assessment and
                                                                           Treatment Act.




                                                                                    Summary of DHB Serious and Sentinel Event Report 2010/11                   51
                                                                                                                                    Tairawhiti District Health Board


Serious    Event   Description of event           Review findings                       Recommendations/actions                               Follow-up
  or       code
sentinel

Serious     4A     Five-month wait for       Information transfer from        Organisational discussion and consultation is         Recent root cause analysis
                   colonoscopy               the Clinical Prioritisation      required to identify and implement, with              review RCA. Work streams to
                   procedure, resulting in   Assessment Criteria              appropriate training to staff, a single               be progressed.
                   delayed treatment.        (CPAC) tool to the surgical      standardised diagnostic/prioritisation tool for use
                                             waiting list (an electronic      throughout the organisation. Ministry of Health
                                             system) require coding but       recommendations to be included in this process.
                                             each uses different codes
                                                                              Ensure that the chosen tool is compatible with
                                             and therefore requires
                                                                              patient management system so that prioritisation
                                             interpretation to best fit the
                                                                              codes are not open to interpretation.
                                             electronic system. This
                                             provides opportunity for         Regular review of waiting list to ensure it is
                                             misinterpretation of the         being managed effectively.
                                             priority of the patient.
                                                                              Computer generated standardised letters to be
                                                                              reviewed. Letter to include full details of who to
                                                                              contact if there is deterioration/change in
                                                                              condition, to encourage patient participation in
                                                                              the process.
                                                                              The timeframe process for the procedure to be
                                                                              transparent and communicated to local
                                                                              communities.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                 52
                                                                                                                             Tairawhiti District Health Board


Serious    Event   Description of event        Review findings                       Recommendations/actions                           Follow-up
  or       code
sentinel

Sentinel    4C     Neonatal death and     Chorioamnionitis with            Intrapartum Fever” guideline including”
                   maternal               Group B strep infection          presumed chorioamnionitis” developed.
                   haemorrhage.           after prolonged induction.       Approved and released August 2011
                                          Intrapartum asphyxia.            CTG training
                                                                               Majority of staff completed K2 training
                                          Failure to correctly interpret
                                                                               New staff to complete K2 training in 1
                                                                                                                        st
                                          CTG tracing and respond
                                          appropriately.                          month
                                                                               Plan to link regionally with RANZCOG
                                          Overall deteriorating clinical          training and aim to achieve all Midwives
                                          situation was not                       and O&G Consultants attending
                                          appreciated.
                                                                           Quality Meetings
                                                                               Weekly MDT Clinical Quality meetings
                                                                                   to review CTG’s, discuss clinical cases
                                                                                   and to encourage open communication
                                                                                   between Midwives and O&G
                                                                                   Consultants.



Serious     5      Patient collapsed                                       RCA in progress.
                   during sedation.
                                                                           Conscious sedation guidelines are under review.




                                                                                   Summary of DHB Serious and Sentinel Event Report 2010/11              53
                                                                                                                                    Taranaki District Health Board



Taranaki District Health Board
www.tdhb.org.nz

 Serious or   Event     Description of                   Review findings                                Recommendations/actions                      Follow-up
  sentinel    code         event

  Serious      1      Wrong patient         Both father and son had exactly the same        Ensure that all referrals have the patient’s NHI             All
                      anaesthetised (son    name and contact details.                       number and date of birth clearly documented.              completed
                      rather than father,
                                            Son was registered on the local Patient         Ensure that when discussing consent with the
                      with same name).
                                            Management System with his National             patient, the consent form is completed, including the
                                            Health Index (NHI) number but the father        identification of the signee.
                                            was not.
                                                                                            Ensure staff read all referrals thoroughly and not
                                            Son had symptoms that correlated with his       accept/enter any referrals that are not completed
                                            father’s surgical diagnosis.                    appropriately. Reminders given to staff.
                                            Son had recently been returned to his           Referral documents are to be reviewed at pre-
                                            mother’s care and displayed symptoms that       admission and anaesthetic assessment
                                            led her to believe that her son was already     appointments.
                                            on the wait list.
                                                                                            Discussion to occur between the contracted provider
                                            The surgical referral form did not contain      hospital and the DHB to identify where streamlining
                                            the patient’s NHI number.                       can occur.
                                            The identification of the signee on the
                                            consent form (ie, patient, parent or
                                            guardian) was not marked.
                                            The procedure for adding a patient to the
                                            surgical waiting list was not followed.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11             54
                                                                                                                                        Taranaki District Health Board


Serious or   Event        Description of                     Review findings                                Recommendations/actions                      Follow-up
 sentinel    code            event

 Serious        1       Wrong patient          (cont’d) The son’s referral document was
 (cont’d)    (cont’d)   anaesthetised          not available and not sighted at pre-
                        (cont’d).              admission clinic.
                                               At the anaesthetic appointment, the
                                               consent/referral form was not viewed.
                                               Staff member competent in the referral onto
                                               the surgical booking list process.
                                               The surgical booking team had undergone
                                               significant changes including reorganisation
                                               of work allocation, staff turnover, increased
                                               workload and added pressure while
                                               recruitment occurred.

 Serious       4A       Delay in diagnosis     The discharge summary was not                   Sending copies of all X-ray results to the patient’s GP   Completed.
                        and treatment for      completed.                                      commenced in 2009.
                        lung cancer that
                                               The Clinical Management of Test Results         Digital radiology commenced in 2009, allowing easier
                        was visible on a                                                                                                                 Completed.
                                               and Investigations procedure was not            access to X-rays.
                        chest X-ray taken in
                                               followed.
                        July 2008.                                                             The Clinical Management of Test Results procedure
                                               Failure to arrange follow-up specifically       has been reviewed and is now a policy.                    Completed.
                                               related to the chest X-ray result.              Responsibilities have been clearly communicated.
                                               When admitted for the operation, the            Explore options where information technology can
                                               patient’s previous chest X-ray result was       assist clinical staff with results management to          In progress.
                                               not noted.                                      improve robustness.
                                               The patient’s chest X-ray result and advice     Explore options for reviewing X-ray results that have
                                               concerning follow-up was not                    not been ‘marked as read’ prior to 2009 and
                                               communicated to the patient or noted in the     implement the best solution.                              In progress.
                                               patient’s discharge summary to the
                                               patient’s GP.

 Serious       4B       Patient presented      Reviewing neurosurgeon to review the case       Report pending.
                        with back pain that    notes and determine whether there are any
                                                                                               [Commission comment: Advised by Taranaki DHB
                        was diagnosed 48       actions to be taken to prevent delay in
                                                                                               after report printed that this case, following review,
                        hours later as an      diagnosis.
                                                                                               was not considered a serious or sentinel event.]
                        epidural abscess.



                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11               55
                                                                                                                                   Taranaki District Health Board


Serious or   Event     Description of                    Review findings                                Recommendations/actions                     Follow-up
 sentinel    code         event

 Serious      4B     Following the death   ‘Difficulty in Swallowing’ form, care plan and   Feedback to staff member and to all ward staff.         Completed.
                     of a patient from a   assessment questionnaire not completed.
                                                                                            Audit/review of nursing documentation for all new       Initiated
                     stroke and
                                           Upper dentures placed in the deceased’s          admissions to commence.                                 and
                     pneumonia, the
                                           mouth, but this was not documented in the                                                                ongoing.
                     DHB was advised                                                        Deliver brief education sessions for all ward staff
                                           patient property book.
                     that the deceased                                                      around oral hygiene and care of the deceased with       Completed.
                     patient’s dentures    Non-compliance with oral hygiene cares in        specific relevance to denture care.
                     were found down       relation to denture care.
                                                                                            Change the current ‘Difficulty in Swallowing’ form to
                     the back of his                                                                                                                Completed.
                                           Coroner investigation progressing.               enable additional details about denture information.
                     throat.
                                                                                            Change the current care plan to allow additional
                                                                                            information relation to oral cares/denture              Completed.
                                                                                            management.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                 56
                                                                                                                                  Whanganui District Health Board



Whanganui District Health Board
www.wdhb.org.nz

 Serious or   Event   Description of event            Review findings                   Recommendations/actions                             Follow-up
  sentinel    code

  Serious      4A     Undiagnosed low           As a result of a full blood      Adjust the cardiac pathway to reflect that     Audit cardiac pathway six-
                      haemoglobin (blood        count not being taken for two    a full blood count is taken every day that a   monthly.
                      count) which resulted     days, a significant drop in      patient is on blood thinning medication.
                      in the patient falling.   haemoglobin was not
                                                                                 Education for RMOs by Pharmacy staff as
                      Patient subsequently      detected.                                                                       Review RMO orientation
                                                                                 part of their orientation.
                      died.                                                                                                     checklists.
                                                Patients in CCU are cared for
                                                                                 Consider increasing the continuity of care
                                                by a different clinician each                                                   To be discussed by the Clinical
                                                                                 for those patient in CCU.
                                                day which has the potential                                                     Board.
                                                to lessen continuity of care.

  Sentinel     1      Anaesthetic given for     Several different conventions    All staff in the dental unit and Patient       Audit six-monthly to ensure
                      tooth extractions that    for documenting the teeth to     Scheduling are to use the recognised           correct numbering system is
                      had been performed        be extracted.                    tooth numbering system when booking            being utilised.
                      two years previously.                                      patients for extractions/repairs.
                                                Surgeons and therapists
                      No ill effects for
                                                documented in different parts    Dental surgeons will document their
                      patient.                                                                                                  Audit six-monthly.
                                                of the patient’s health record   treatments and surgeries in the therapists’
                                                and did not read each other’s    section of the health record to ensure that
                                                documentation.                   all involved in the patient’s care are aware
                                                                                 of what has already taken place.
                                                Booking sheet completed by
                                                dental unit staff and not        All booking sheets for dental surgery are
                                                signed off by surgeon, as he     to be reviewed and signed off by the           Audit six-monthly.
                                                lived out of town.               surgeon before being sent to Patient
                                                                                 Scheduling.
                                                Dental X-ray unit was out of
                                                order, waiting for parts.        The signed booking sheets must be
                                                Dental X-ray from 2008 was       accompanied by a complete dental X-ray         Audit six-monthly.
                                                erroneously filed with the       when forwarded to Patient Scheduling.
                                                booking sheet.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11                  57
                                                                                                                                Whanganui District Health Board


Serious or   Event   Description of event            Review findings                   Recommendations/actions                             Follow-up
 sentinel    code

 Serious      5      Patient found             Patient admitted to the Day      All medications should be checked and         Pharmacy staff to monitor.
                     unconscious after         Unit. Medicine reconciliation    written on a medication chart prior to
                     administration of         did not occur before patient’s   transfer to the ward from the day unit. If
                     morning medications,      surgery. RMO prescribed          this   cannot      be   completed,  then
                     which patient should      medications from patient’s       medications may have to be withheld and
                     not have been             own medication card,             the patient monitored until medicine
                     prescribed, and           however, the anti-               reconciliation is completed.
                     required transfer to      hypertensive medications
                                                                                Education regarding blood pressure and        Conducted.
                     CCU. Patient made a       had been discontinued some
                                                                                anti-hypertensive medications to be
                     full recovery.            time ago.
                                                                                conducted.

 Serious      4B     Failure to make           Electronic discharge             Tutorial for RMOs on the correct use of       Ongoing.
                     outpatient appointment    summary stated outpatient        the follow-up section of the electronic
                     resulting in a delay in   appointment to be made in        discharge summary.
                     treatment.                one week; however, this was
                                               not written in the ‘follow-up
                                               appointments to be made’
                                               section, and was overlooked
                                               by administration staff.
                                               An audit of discharge
                                               summaries showed
                                               inconsistency in recording
                                               follow-up appointments.

 Serious      6      Admitted to surgical      No evidence of written or        Written copy of patient care instructions     Template for instructions
                     ward, as a blistery       verbal instructions given by     must be given to patient prior to             developed March 2011.
                     rash had developed        clinic regarding plaster care    discharge. All verbal instructions given to
                     under a leg plaster.      and symptoms to look out         patient must be listed in patient notes.
                     While mobilising in the   for.                                                                           New falls risk assessment tool
                                                                                All staff on the surgical ward to have an
                     ward, patient fell and                                                                                   introduced and end of bed falls
                                               No falls risk care plan          understanding and awareness of the new
                     fractured a hip,                                                                                         care plan implemented April 2011.
                                               implemented on admission.        Falls Injury Prevention Standard by 1 April
                     requiring surgery.
                                                                                2011.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11             58
                                                                                                                                 Whanganui District Health Board


Serious or   Event   Description of event             Review findings                  Recommendations/actions                              Follow-up
 sentinel    code

 Sentinel     4A     15-month delay in          Chest X-ray taken prior to      Patient’s GPs to be sent a copy of all X-      Completed.
                     diagnosing         lung    dental surgery showed a lung    ray reports generated from the dental unit.
                     cancer.       Palliative   lesion.
                                                                                Previous chest X-ray films/reports must
                     treatment undertaken
                                                Patient presented to ED with    be viewed when an abnormality is
                     and     patient    died
                                                chest pain, lesion was larger   detected.                                      Ongoing.
                     several months later.
                                                and had spread
                                                (metastisised).
                                                No copy of X-ray report sent
                                                to GP.
                                                Previous chest X-rays not
                                                reviewed.

 Serious      5      Medication given in        Order of Theatre list was       Develop a flow chart for premed options        Completed.
                     incorrect order,           changed at short notice due     including timeframes and patient
                     resulting in patient       to a hole in the instrument     presentation.
                     experiencing               wrapping being detected.
                                                                                Replace sterile tray shelving units to allow
                     temporary paralysis        This resulted in the patient
                                                                                for better storage of sterile trays.           Audit in six months for
                     prior to procedure in      not being mentally prepared
                                                                                                                               compliance.
                     theatre. Patient           and it was thought there was    Consider protective devices for corners of
                     traumatised by the         no time to administer a pre-    instrument trays to prevent inadvertent
                     event.                     medication.                     piercing of sterile packing.
                                                Anaesthetic medications         Introduce red-barrelled syringes for
                                                drawn up and syringes were      paralysing agents.                             Under way.
                                                labelled; however, incorrect
                                                                                Research and implement anxiety rating
                                                syringe used.
                                                                                scale to accurately identify patients’
                                                Patient known to be anxious     anxiety.
                                                on previous occasions and
                                                                                Review Pre-operative Checklist. Include
                                                this was not adequately                                                        Implement and audit in six months
                                                                                section for anxiety rating scale and
                                                responded to by staff.                                                         for compliance.
                                                                                notification of who the patient wishes
                                                                                information to be given to such as next of
                                                                                kin/support person. Benchmarking with
                                                                                other DHBs is recommended.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11              59
                                                                                                                                 Whanganui District Health Board


Serious or   Event   Description of event             Review findings                     Recommendations/actions                           Follow-up
 sentinel    code

 Serious      6      Patient fell from beside   Palliative care patient            Patient was placed on constant
                     bed, resulting in hip      assessed as a very high falls      supervision.
                     fracture.                  risk. All appropriate falls risk
                                                                                   All staff made aware of the Whanganui
                                                minimisation measures                                                          Completed. Centre for Patient
                                                                                   DHB’s Open Disclosure policy and timely
                                                instituted, including bell mat                                                 Safety will monitor compliance
                                                                                   communication with families.
                                                alarm. Alarm sounded, staff                                                    with the Open Disclosure policy.
                                                responded immediately but
                                                patient had already fallen.
                                                There was a delay in
                                                informing the family of the
                                                event.

 Serious      4A     Delay in responding to     Junior medical staff did not       Tutorial held for junior medical staff to   Completed.
                     deteriorating patient      escalate their concerns to         improve communication competency.
                     post-operatively.          senior medical staff.
                                                                                   The surgical team have conducted in-
                     Patient required further                                                                                  Completed.
                                                Nursing staff did not follow       service ‘recognition of the acute
                     extensive bowel
                                                the early warning score            abdomen’.
                     surgery and transfer to
                                                protocol and notify the Duty
                     a tertiary facility                                           Requirements of Health Records Policy       Audit six-monthly.
                                                Nurse Manager about the
                     Intensive Care Unit.                                          and documentation standards reiterated
                                                patient’s condition.
                                                                                   to all staff.
                                                Once the deterioration was
                                                recognised the patient’s vital
                                                signs were closely
                                                monitored; however, not all
                                                recordings were
                                                documented.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11           60
                                                                                                                                          Hawke’s Bay District Health Board



Hawke’s Bay District Health Board
www.hawkesbay.health.nz

 Serious or   Event   Description of event                   Review findings                       Recommendations/actions                             Follow-up
  sentinel    code

Sentinel       6      Fall    resulting   in        Falls risk assessment completed           In-service education to include falls         Hospital falls project expanded
                      fractured hip. Patient        and falls prevention strategies           minimisation.                                 scope of responsibility for falls
                      died three days post          incorporated into care plan.                                                            minimisation to be district-
                      fall.                                                                                                                 wide.
                                                    Staff   member     left   patient
                                                    unsupported for a short period of
                                                    time.

Sentinel       6      Fall      resulting      in   Falls risk assessment completed           No recommendations.
                      fractured hip and arm         and falls prevention strategies
                      and      head       injury.   incorporated into care plan.
                      Patient died 23 days
                                                    Fall result of impulsive behaviour.
                      post fall.
                                                    Aspiration        pneumonia           a
                                                    contributing factor to death.

Sentinel       4A     Failure    to identify        Failure to recognise deteriorating        Fetal monitoring training for staff.          Education completed.
                      maternal and fetal            condition.
                                                                                              Review clinical responsibility between        Policies  and    procedures
                      deterioration  during
                                                    Miscommunication       between            independent midwife and hospital              reviewed,          including
                      labour.
                                                    independent midwife and medical           team.                                         communication methods.
                      Infant died several           staff.
                                                                                              Review methods of communication               Awaiting Coroner’s findings.
                      hours after birth.
                                                                                              with patients and between clinical staff.
                                                                                              Referred to the Coroner.

Serious        4G     Delayed diagnosis due         Patient   waiting    greater   than       Review management of endoscopy                Full clinical and administration
                      to failure to schedule        expected time for colonoscopy.            waiting list systems and processes.           review      of    waiting     list
                      appointment      within                                                                                               completed.
                                                    Patient postponed for more urgent
                      required timeframe.
                                                    case.                                                                                   Access criteria developed.
                                                                                                                                            Resources reviewed.
                                                                                                                                            Waiting times improved.



                                                                                               Summary of DHB Serious and Sentinel Event Report 2010/11                    61
                                                                                                                                 Hawke’s Bay District Health Board


Serious or   Event   Description of event               Review findings                    Recommendations/actions                           Follow-up
 sentinel    code

Serious       4B     Delayed diagnosis and     Abnormal X-ray       findings   not    Review guideline for routine        pre-     In progress.
                     treatment   due     to    followed up.                           operative investigations.
                     failure to act on
                                               GP name not entered in radiology       Review sign-off process for abnormal
                     abnormal radiological
                                               system until after report finalised.   radiology results.
                     findings.
                                                                                      Ensure GPs are always assigned in
                                                                                      the radiology system so they receive a
                                                                                      copy of the finalised report.

Serious       4A     Delayed diagnosis due     Shortage of radiologist resource.      Increase/recruit radiologist resource.       Additional radiologist
                     to failure to schedule    Implementation of new electronic                                                    employed.
                                                                                      Develop and implement clinical
                     radiology     procedure   radiology system resulted in patient
                                                                                      indicators/flags for monitoring CT           Electronic radiology     system
                     and delayed radiology     report delays.
                                                                                      colonoscopy waiting times.                   implemented.
                     reporting following the
                     procedure.                                                                                                    Reporting volumes are being
                                                                                                                                   monitored.
Serious       4A     Procedure delay and
                     reporting      delay
                     resulting in delayed
                     diagnosis.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                 62
                                                                                                                                   MidCentral District Health Board



MidCentral District Health Board
www.midcentraldhb.govt.nz

 Serious or   Event      Description of event                    Review findings                         Recommendations/actions                   Follow-up
  sentinel    code*

Serious        4A     Fall resulting in fractured    Fracture occurred prior to admission          Colour, warmth and movement, and             Completed.
                      ankle prior to admission.      during cardiac arrest when patient fell at    sensation assessments to be completed
                      Diagnosis delayed by four      home. Was missed by staff for four            early where potential bony injuries
                      weeks.                         weeks until patient began mobilising. X-      identified.
                                                     ray immediately ordered and fracture
                                                     noted.

Sentinel       4C     Patient found dead during      No causal factors were identified in this     Review the observation policy and            Completed.
                      morning round.                 incident. Regular overnight checking was      procedure for the detail of the inspection
                                                     completed, however more in-depth              process that is required overnight.
                                                     inspections are required.

Serious        4D     A haemodialysis machine        The process flow for the management of        Strengthen standards for process and         Completed.
                      was not disinfected prior to   dirty to clean machines was not clear and     flow of cleaning haemodialysis machines.
                      connection to patient. No      was impacted by inadequate storage
                                                                                                   Identify additional storage space to have
                      identified harm to patient.    space.
                                                                                                   clean and dirty machines separated.

Serious        5      Incorrect dose of              10 times correct dose of Methadone            Review and strengthen medication             Completed.
                      Methadone administered.        given (ie, 50ml instead of 5ml) as a result   checking process in specialist units when
                                                     of the unfamiliarity with medication.         staff are unfamiliar with medication.
                                                     Intensive monitoring of patient was
                                                                                                   Explore options for obtaining lower
                                                     required.
                                                                                                   strength medication (ie, 1mg/ml).

Serious        3      Part of a surgical             An additional instrument was brought into     Revise and strengthen process to ensure      Completed.
                      instrument left in abdomen     theatre during the surgery and was not        all instruments used in surgery are
                      following surgery.             added to the count.                           included on count lists.
                      Subsequently the patient
                      was returned to theatre for
                      removal of the retained
                      instrument part.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11              63
                                                                                                                              MidCentral District Health Board


Serious or   Event      Description of event                    Review findings                      Recommendations/actions                  Follow-up
 sentinel    code*

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 fluid
                     anaesthetic, resulting in
                                                    management 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 fresh 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.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11           64
                                                                                                                                   MidCentral District Health Board


Serious or   Event      Description of event                      Review findings                      Recommendations/actions                     Follow-up
 sentinel    code*

Serious       6      Inpatient fall resulting in     Patient fell while walking from toilet to    The following generic recommendations        The Falls Action
                     scalp laceration and            hand basin. Staff not present when fall      apply to all falls:                          Group has been
                     fracture of hip.                occurred. Falls risk assessment was                                                       strengthened and
                                                     completed on admission.                         review organisation-wide falls           a detailed plan
                                                                                                      reduction programme                      developed to
Serious       6      Fall resulting in fractured     Patient mobilising independently. Had a         implement evidence-based best            ensure that the
                     wrist.                          shower and reached for towel and lost            practice initiatives to reduce falls.    target of Falls
                                                     balance. Fell to the ground and used                                                      Injury Reduction
                                                     wrist to break fall. Falls risk assessment                                                in the 2011/12
                                                     completed on admission and was not                                                        Annual Plan is
                                                     assessed as a risk. All appropriate steps                                                 met. Whilst there
                                                     taken.                                                                                    are components
                                                                                                                                               of both risk
Serious       6      Fall whilst an inpatient        Fall occurred when patient was getting                                                    assessment and
                     resulting in skin tears and     out of bed and used chair to assist with                                                  falls prevention
                     fractured hip.                  standing. Chair moved and patient fell to                                                 strategies in place
                                                     the ground. Unwitnessed fall. Patient had                                                 they are not well
                                                     been assessed as a falls risk and was                                                     co-ordinated.
                                                     confused.                                                                                 Both national and
                                                                                                                                               international
Serious       6      Fall resulting in fracture of   Patient assisted to toilet. When patient                                                  evidence will be
                     hip and increased hospital      turned to sit on toilet, leg gave way and                                                 used to
                     stay.                           patient fell to the ground twisting leg.                                                  strengthen falls
                                                     Patient was on assisted walking and                                                       prevention.
                                                     toileting.

Serious       6      Patient fall resulting in       Unable to accurately define when
                     fractured hip.                  fracture took place or how the event
                                                     occurred.
                     Event not observed.

Serious       6      Patient fall resulting in       Patient had been independently
                     fractured hip.                  mobilising with low frame. Assessed as
                                                     nil falls risk prior. Patient fell whilst
                                                     moving from frame to toilet seat.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11              65
                                                                                                                                MidCentral District Health Board


Serious or   Event      Description of event                  Review findings                          Recommendations/actions                  Follow-up
 sentinel    code*

Serious       6      Patient fall resulting in   Patient had gone for a short walk and
                     fractured wrist.            was found outside the ward by the lift.
                                                 Fall was unwitnessed. Patient not able to
                                                 state how they fell.

Serious       6      Patient fall resulting in   Patient fell when getting up from toilet.
                     fractured left arm.         Had a history of falls. Staff member with
                                                 patient at the time of fall but was unable
                                                 to completely stop injury occurring. All
                                                 appropriate actions taken.

Serious       6      Patient fall resulting in   Patient was transferring back to bed.
                     fractured left arm.         Transfer was unsteady which resulted in
                                                 patient landing on arm on bed.

Serious       6      Patient fall resulting in   No identified risk of falls. Fell on the way
                     fractured right arm.        to toilet after hitting water cooler. At time
                                                 of fall patient was wearing slippers that
                                                 may have contributed. All appropriate
                                                 actions had been taken prior to fall.

Serious       6      Patient fall resulting in   Patient was attempting to mobilise out of       Patients to be advised to wear non-slip
                     fractured hip.              bed to go to toilet. Was wearing socks at       footwear.
                                                 the time and slipped beside bed falling to
                                                                                                 Also as above.
                                                 the floor.

Serious       6      Patient fall resulting in   Patient had a previous stroke with limited      Revise the approach to management of
                     fractured hip.              mobility. Escorted to toilet and given          privacy for patients at risk of falling.
                                                 privacy. Whilst nurse out of room, patient
                                                                                                 Also as above.
                                                 attempted to stand up resulting in fall.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11             66
                                                                                                                                 Wairarapa District Health Board



Wairarapa District Health Board
www.wairarapa.dhb.org.nz

 Serious or   Event   Description of event                 Review findings                      Recommendations/actions                         Follow-up
  sentinel    code

  Serious      6      Patient fall resulting in   Patient was assessed as being at       Reviewed as part of the Falls Management     Closed.
                      a fractured hip             risk of falling and precautions had    Group, and also by reportable event group.
                      requiring surgery.          been taken.                            No actions identified which could have
                                                                                         mitigated the fall.

  Serious      6      Patient fall resulting in   Patient was assessed as being at       Reviewed as part of the Falls Management
                      a fractured rib.            risk of falling and had been visited   Group, and also by Reportable Events
                                                  by the nurse and checked 10            Group. Patient was in a single room for
                                                  minutes before the fall.               infection prevention management; ideally
                                                                                         would have been more observable in a
                                                                                         four-bed bay. Infection prevention team
                                                                                         looking at more effective observation
                                                                                         methods for patients under standard
                                                                                         precaution management in single rooms.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11            67
                                                                                                                                 Hutt Valley District Health Board



Hutt Valley District Health Board
www.huttvalleydhb.org.nz

 Serious or   Event   Description of event                Review findings                           Recommendations/actions                       Follow-up
  sentinel    code

  Serious      12     Patient death in         Number of issues identified relating to    Replace floor coverings in ward.                     Appropriate
                      hospital following       clinical management and physical                                                                changes
                                                                                          Review environmental cleaning practice.
                      hospital-acquired        environment.                                                                                    recommended
                      infection (rotavirus).                                              Ongoing education for staff regarding hand           have been
                                                                                          hygiene, appropriate use of personal protective      implemented in
                                                                                          equipment, recognition of sick child and role of     ward.
                                                                                          infection prevention and control team.
                                                                                          Review instruction sheets for making up
                                                                                          concentrated feeds.
                                                                                          Review use of short stay observation chart.

  Sentinel     4G     Patient death in         External review highlighted a number       20 recommendations from the review are in an
                      hospital following       of systems and process issues related      action plan including:
                      admission for            to the communication and co-
                      suspected overdose.      ordination of care through primary and        implementation of a case management/key
                                               secondary services and whilst in               worker model of care to ensure that patient
                                               hospital that may have contributed to          care is co-ordinated between services
                                               the patient’s death.                          improve communication and inter-service
                                                                                              relationships, including inter-ward and inter-
                                                                                              DHB transfers
                                                                                             improve integration of mental health records
                                                                                              and medical records
                                                                                             implement an organisation-wide morbidity
                                                                                              and mortality review process.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11               68
                                                                                                                                     Hutt Valley District Health Board


Serious or   Event   Description of event                   Review findings                             Recommendations/actions                       Follow-up
 sentinel    code

 Sentinel     6      Patient fall.               Patient admitted with significant co-        Fall ‘hot-spots’ mapping under way as part of       Falls Prevention
                     Subsequently found to       morbidities and poor prognosis.              hospital-wide Falls Prevention Project.             Project ongoing
                     have fracture. Patient      Assessed as moderate falls risk on                                                               and added to
                                                                                              All falls documentation and effectiveness of
                     died following surgery      admission. During admission falls risk                                                           organisation wide
                                                                                              same under review.
                     to repair fracture.         increased and 15-30 minute check                                                                 key performance
                                                 protocol implemented. Patient had            Falls incidence and prevention standing agenda      indicators.
                                                 surgical repair of fracture on day after     item at ward meetings.                              Progress
                                                 fall. Surgery successfully completed,                                                            monitored on a
                                                 but patient condition deteriorated post                                                          quarterly basis by
                                                 operation; died three days after the fall                                                        Patient Safety
                                                 occurred.                                                                                        Leadership
                                                                                                                                                  Group.

 Serious      6      Patient fall resulting in   Patient fell whilst independently            Review completed. Chair sensor pad trialled         Falls prevention
                     fracture.                   transferring from chair to bed.              with patient – this worked well following event     project ongoing
                                                                                              and trial will be extended for other patients.      and added to
                                                                                                                                                  organisation-wide
                                                                                                                                                  key performance
                                                                                                                                                  indicators.
                                                                                                                                                  Progress
                                                                                                                                                  monitored on a
                                                                                                                                                  quarterly basis by
                                                                                                                                                  Patient Safety
                                                                                                                                                  Leadership
                                                                                                                                                  Group.




                                                                                             Summary of DHB Serious and Sentinel Event Report 2010/11             69
                                                                                                                                     Capital & Coast District Health Board



Capital & Coast District Health Board
www.ccdhb.org.nz

From 1 July 2009, Capital and Coast DHB stopped using the terminology ‘serious’ and ‘sentinel’ and adopted Severity Assessment Code (SAC) rating terminology in
accordance with the draft national policy on reportable events. SAC1 and SAC2 events are broadly comparable, respectively, with “Sentinel” and “Serious” events.

 Serious      Event        Description of event              Review findings                 Recommendations/actions                              Follow-up
   or         code
 sentinel

 Serious        11        Patient self-harm. Police   The review concluded that         The review did not make any                   Not applicable. Closed.
                          involved in response.       appropriate actions and           recommendations.
                                                      decisions were made in
                                                      respect of the management of
                                                      the patient.

 Serious        4B        Child seen twice on         Review found that care            Review recommended the hospital               Referred to Coroner at time of
                          same day at hospital        provided by the hospital clinic   clinic protocol be amended to specify         event. Coroner decision not to
                          clinic. Transferred to      was appropriate. Review           that antibiotics be given in the clinic to    open an inquiry. Coroner
                          hospital emergency          identified a delay in the         any patient suspected to be suffering         reconsidering need for inquiry at
                          department on second        administration of antibiotics     from meningococcal septicaemia.               request of family.
                          presentation. Patient       due to the transfer time from     Review also recommended that the
                                                                                                                                      The Paediatric Service and
                          died in Intensive Care      the clinic to the emergency       DHB apologise to the family for the
                                                                                                                                      hospital clinic have revised the
                          Unit later that day.        department.                       delay in administration of antibiotics.
                                                                                                                                      protocol for antibiotic
                          Meningococcal
                                                                                                                                      administration. Report and
                          septicaemia.
                                                                                                                                      apology provided to family.

 Serious        4B        Significant deterioration   Review found that while overall   Review recommended an education               The education plan and the
                          of existing pressure area   care was appropriate and the      plan to develop staff further on              process for management of
                          during hospital             pressure area was at high risk    pressure area management and                  complex wounds were developed
                          admission.                  of deterioration, some aspects    wound expertise, the development of a         and implemented and
                                                      of communication of wound         process for management of complex             communication processes
                                                      care assessment and               wounds and strengthening of                   between inpatient and community
                                                      management were not               communication between inpatient               nurses strengthened. Closed.
                                                      consistent and not escalated      areas and community nurses.
                                                      when indicated.




                                                                                            Summary of DHB Serious and Sentinel Event Report 2010/11                     70
                                                                                                                       Capital & Coast District Health Board


Serious    Event    Description of event            Review findings                Recommendations/actions                          Follow-up
  or       code
sentinel

Sentinel    11     Apparent intentional       Review found that the action     Review did not make any                  Referred to Coroner at time of
                   removal of vascular        by the patient could not have    recommendations                          event. Coroner decision not to
                   catheter by patient.       been predicted and that staff                                             open an inquiry.
                   Despite emergency          had acted appropriately when
                   response the patient       the incident occurred.
                   died.

Serious     4B     Patient admitted due to    Review found that while a        Review recommended that a formal         A process has been developed
                   a complication one day     delay had occurred in            process for the introduction of new      and implemented for the
                   after having had           removing the PEG, the            equipment to the service be developed    introduction of new equipment to
                   insertion of a tube into   patient’s care was appropriate   and implemented and that a check be      the service. A patient education
                   the stomach                and there were no significant    completed to ensure all necessary        brochure has been developed at
                   (Percutaneous              clinical concerns about the      equipment is stocked.                    the request of the patient’s family
                   Endoscopic                 PEG remaining in place until                                              and is available.
                   Gastrostomy tube –         the equipment was available.
                                                                                                                        Closed.
                   PEG). The tube was         The review team did not
                   removed four days later    consider that the delay
                   (delayed removal). The     contributed to the outcome.
                   patient died later that
                                              Review identified that the
                   day.
                                              delay occurred because the
                                              type of PEG tube had not
                                              previously been used in the
                                              department and specialist
                                              equipment for removal was not
                                              immediately accessible.

Serious     4B     Patient presented with     Review identified that the       Review recommended informing the         The primary provider was informed
                   bronchial carcinoma. It    radiology report was             primary provider of the event and        and subsequently confirmed that
                   was identified that a      communicated to the patient’s    outcome of DHB review, ensuring the
                   chest X-ray taken two      GP and that a clearer process    patient had been informed, and
                                                                                                                        the patient had been informed.
                   years previous showed      for direct communication of      development of a more robust system      Work is in progress to strengthen
                   an opacity and             such results should be           for communication and follow-up of       the system for communication and
                   recommended further        developed as there was a lack    reports.                                 follow up of reports of unexpected
                   investigation.             of clarity as to who was                                                  findings on chest x-ray.
                                              following up the result.




                                                                                  Summary of DHB Serious and Sentinel Event Report 2010/11               71
                                                                                                                                Capital & Coast District Health Board


Serious    Event     Description of event               Review findings                   Recommendations/actions                            Follow-up
  or       code
sentinel

Serious     4C      Patient deterioration.       Review found patient’s              Review endorsed the DHB’s existing          Referred to Coroner at time of
                    Concern that there was       treatment was in keeping with       implementation of an Early Warning          event.
                    a delay in transfer to the   clinical guidelines, although in    Score Chart and mandatory Medical
                                                                                                                                 The Early Warning Score Chart
                    Intensive Care Unit.         hindsight earlier transfer to       Emergency Team call system for
                                                                                                                                 and the mandatory Medical
                    Patient died.                Intensive Care should have          predetermined parameters.
                                                                                                                                 Emergency Team call system
                                                 been undertaken.
                                                                                     Review also recommended that the            have been implemented. The
                                                                                     service agree the most appropriate          service has agreed the pathway
                                                                                     pathway for the care of complex             for the care of complex patients.
                                                                                     patients experiencing deterioration;        The Patient at Risk team are able
                                                                                     and to consider whether the Patient at      to contact the ICU registrar or
                                                                                     Risk team should have the ability to        consultant at any time if
                                                                                     directly request the opinion of an          concerned about a patient’s
                                                                                     Intensive Care doctor where they are        condition.
                                                                                     concerned regarding patient
                                                                                     management.

Serious    4B & 5   Unexpected patient           Review found that the main          Review recommended development of           It was identified that the death
                    death following              factor that contributed to the      organisation wide guidelines for the        had not been referred to the
                    anticoagulant treatment      patient’s death was the             diagnosis and treatment of non-STEMI        Coroner at the time. Coroner
                    for suspected heart          decision to treat the patient for   myocardial infarction (heart attack) and    subsequently notified.
                    attack (non-STEMI            a non-STEMI myocardial              that the guidelines be developed and
                                                                                                                                 Development of the guideline is
                    myocardial infarction).      infarction (heart attack) on the    agreed between the emergency,
                                                                                                                                 under way.
                                                 basis of Troponin T test            cardiology and internal medicine
                                                 results. Review also noted          services.
                                                 that double the intended dose
                                                 of anticoagulant was
                                                 prescribed and given as a first
                                                 dose due to human error, and
                                                 that an algorithm included in
                                                 guidance related to a new high
                                                 sensitivity Troponin T test may
                                                 contribute to the risk of such
                                                 an event.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11                   72
                                                                                                                      Capital & Coast District Health Board


Serious    Event    Description of event              Review findings                Recommendations/actions                       Follow-up
  or       code
sentinel

Sentinel    11     Patient death in            Review found that the patient’s   The review made no recommendations. Police referred to Coroner at time
                   community. Patient had      assessment was fully                                                  of event (as death occurred in
                   been admitted that day      completed and the appropriate
                   for suspected deep vein     treatment pathway was
                                                                                                                     community).
                   thrombosis (DVT – clot).    commenced prior to the leave.
                   The patient had been        The decision to allow the leave
                   allowed short-term leave    was based on established
                   to return for ultrasound    practice of treating such
                   scan. Patient died a few    patients on an outpatient
                   hours after taking leave.   basis. The review team
                                               consider this patient received
                                               appropriate care and did not
                                               identify any deviation from
                                               usual practise. The review
                                               team concluded that the DVT
                                               pathway is appropriate and
                                               supported by current research-
                                               based practice and no
                                               modifications were required.

Serious     4F     Patient required Medical    Review in progress.
                   Emergency Team call
                   upon arrival in ward
                   after transferring from
                   the Emergency
                   Department.

Serious     4B     Patient admitted within     Review in progress.
                   24 hours of procedure
                   (angiogram). Patient
                   deterioration and death.
                   Concerns regarding co-
                   ordination and level of
                   care.




                                                                                    Summary of DHB Serious and Sentinel Event Report 2010/11           73
                                                                                                                          Capital & Coast District Health Board


Serious    Event    Description of event             Review findings                 Recommendations/actions                           Follow-up
  or       code
sentinel

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.
                   bolus dose of              error in the set-up of the
                                                                                                                           updated including specific process
                   syntocinon during labour   syntocinon infusion through a                                                for checking and pump set up.
                   that resulted in the       pump.                                                                        Staff refresher education re
                   woman requiring an                                                                                      Management of Healthcare
                   emergency caesarean.                                                                                    Incidents/ Open Communication
                                                                                                                           Policies completed.




                                                                                    Summary of DHB Serious and Sentinel Event Report 2010/11                  74
                                                                                                                              Capital & Coast District Health Board


Serious    Event    Description of event               Review findings                 Recommendations/actions                             Follow-up
  or       code
sentinel

Sentinel    6      Patient fall while medical   Review in progress.
                   and nursing staff
                   present during ward
                   round. Patient
                   subsequently
                   deteriorated, transferred
                   to ICU (diagnosis of
                   extradural haematoma).
                   Patient died.

Serious     11     Failure of messaging         The messaging failure was not     Review recommended the learning              Learning has been shared with
                   from laboratory              initially recognised due to       from this event be shared with               neighbouring DHB, primary and
                   information system to        intermittent nature.              neighbouring DHB, primary and                secondary services. The need for
                   hospital clinic meant that                                     secondary services to review the way         a system for sign-off of results
                                                Once identified and fixed there
                   laboratory results were                                        their results are sent out, and to           has been included in current
                                                was a lack of end-to-end
                   intermittently received                                        endorse the need for a system for the        Information Technology System
                                                testing which meant that the
                   by the clinic for nearly                                       sign-off of results that ideally includes    project for electronic results.
                                                resend of the results was not
                   two months in 2010.                                            a process to identify outstanding            Audits are being implemented.
                                                complete and this was not
                                                                                  results. Review also recommended
                                                identified for several months.
                                                                                  continuation of end-to-end audits,
                                                All results were then reviewed    further enhancements to message
                                                and re-sent to general            monitoring, and a system for regular
                                                practitioners. A small number     analysis of similar incidents to identify
                                                of patients needed to be          potential trends/systemic issues.
                                                advised and followed up.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11                 75
                                                                                                                           Nelson Marlborough District Health Board



Nelson Marlborough District Health Board
www.nmdhb.govt.nz

 Serious or   Event   Description of event                    Review findings                               Recommendations/actions                       Follow-up
  sentinel    code

  Serious      4B     A 42-week gestation         Avoidable upper airway obstruction.           Review the discharge and transfer process between
                      infant developed                                                          the recovery area and postnatal ward.
                      breathing difficulties
                                                                                                Ensure that orderlies are utilised for transporting the
                      during transfer to the
                                                                                                patient during transfer enabling the escorting
                      postnatal ward.
                                                                                                midwife to care as required in line with NMDHB
                                                                                                policy for internal transfer of patients.
                                                                                                Review of postpartum care following operative
                                                                                                delivery to afford continuity of midwifery care to
                                                                                                mothers and infants.
                                                                                                District-wide policy review to provide guidance for
                                                                                                midwives regarding appropriate supervision of
                                                                                                mother and infant whilst breastfeeding during
                                                                                                transfer, especially if mother affected by sedative
                                                                                                medication.
                                                                                                Review the appropriateness of the number and
                                                                                                placement of resuscitaires and consider the need
                                                                                                for permanent placement in theatre/recovery area.

  Serious      6      Patient        sustained    The patient’s fall was an unforeseeable       Nil.
                      bilateral wrist fractures   incident. Appropriate assessment and
                      as a result of a fall on    intervention occurred specific to the
                      an inpatient unit. The      patient’s mobility needs.
                      patient died several
                      days later of an
                      unrelated cause.




                                                                                            Summary of DHB Serious and Sentinel Event Report 2010/11             76
                                                                                                                       Nelson Marlborough District Health Board


Serious or   Event   Description of event                   Review findings                              Recommendations/actions                     Follow-up
 sentinel    code

 Serious      6      Patient sustained a       The falls assessment tool used by the         The NMDHB falls prevention project team is
                     fractured hip as a        NMDHB tended to result in underscoring        undertaking a review of the current falls prevention
                     consequence of a fall     and thus false negatives with regard to       programme which includes consideration of the use
                     whilst a medical          the identification of patients at increased   of alternative validated risk assessment tools.
                     inpatient.                risk of falls. This patient was incorrectly
                                                                                             In the interim: amendments to be made to the
                                               considered to be a low as opposed to
                                                                                             current falls risk assessment to correct errors noted
                                               medium falls risk and therefore
                                                                                             in the impaired mobility and altered cognitive state
                                               appropriate risk reduction strategies were
                                                                                             items.
                                               not put in place.
                                                                                             Memo sent to all heads of department to draw
                                                                                             attention to the errors, with support from nurse
                                                                                             educators to reinforce this message.

 Sentinel     4G     A patient experienced     The patient had showed initial signs of       Formalisation of the referral process of acute ENT
                     a cardio-respiratory      clinical improvement following institution    patients between hospitals.
                     arrest five days          of medical treatment. However, it
                     following admission for   transpired the patient had an abscess that
                     an acute ENT (ear,        also required surgical drainage. A CT
                     nose and throat)          scan would have helped establish this
                     condition. The patient    diagnosis and change the course of
                     died eight days later     treatment but was not performed due to a
                     following the             coexisting medical contra-indication.
                     withdrawal of active      Transfer to ENT specialist care was
                     treatment.                considered but not undertaken due to the
                                               initial improvement in the patient’s
                                               condition.

 Serious      6      A patient fell and        There was no documentation pertaining to      Review falls risk assessment processes at NMDHB
                     sustained a fractured     overall clinical assessment of the patient,   Day Stay Units.
                     hip following             including the risk of falls and management
                                                                                             Education to Day Stay Unit nursing staff on
                     admission to the Day      at the Day Stay Unit prior to the planned
                                                                                             completion of nursing assessment and care plans.
                     Stay Unit, prior to a     procedure.
                     surgical procedure.                                                     Audit of nursing documentation and care plans
                                                                                             three months following the above education.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11             77
                                                                                                                         Nelson Marlborough District Health Board


Serious or   Event   Description of event                    Review findings                               Recommendations/actions                      Follow-up
 sentinel    code

Serious       6      A patient sustained a      The falls risk assessments undertaken at       Memo circulated to nursing staff re updating falls
                     fractured hip in a fall    pre-admission clinic and on the day of         risk assessment in nursing care plan as clinically
                     on the surgical ward       admission placed the patient at the lower      indicated and to put in place appropriate steps to
                     four days following an     end of the scoring range for medium risk.      reduce the risk of falls and/or consequent injury.
                     elective right total hip
                                                Further, the falls risk was not formally
                     replacement.
                                                reassessed at any stage to reflect
                                                changes in the patient’s condition which
                                                further increased the falls risk and
                                                indicated the need for a revision of the
                                                care plan.

Serious       6      A patient fell and         The patient was incorrectly assessed as        New falls prevention programme to be
                     sustained a fractured      being a medium as opposed to high falls        implemented. This will include identification of falls
                     hip one week following     risk at the time of admission, due to a        prevention champion and education to nursing staff
                     admission. The patient     scoring error on the current falls risk        in all ward areas.
                     died 11 days later from    assessment (as noted in a previous case).
                                                                                               Re-circulate memo to all heads of department to
                     a pre-existing and         The falls risk was not formally reassessed
                                                                                               draw attention to the error in current falls
                     unrelated cause.           at any stage of the admission despite the
                                                                                               assessment, with support from nurse educators to
                                                emergence of a number of subsequent
                                                                                               reinforce this message.
                                                clinical factors that further increased the
                                                falls risk.                                    Memo circulated to nursing staff re updating falls
                                                                                               risk assessment in nursing care plan as clinically
                                                                                               indicated and to put in place appropriate steps to
                                                                                               reduce the risk of falls and/or consequent injury.
                                                                                               Delivery of delirium teaching package to ward
                                                                                               nursing staff including NMDHB confusion and
                                                                                               delirium guidelines.

Serious       6      A patient fell and         The patient was identified a high falls risk   Nil.
                     sustained a fractured      on admission and appropriate measures
                     hip nine days following    taken to manage this risk. Nonetheless
                     surgery for a fractured    the patient sustained a fractured neck of
                     right neck of femur        femur in an unwitnessed fall.
                     sustained in an earlier
                     fall at home.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11             78
                                                                                                                           West Coast District Health Board



West Coast District Health Board
www.westcoastdhb.org.nz

 Serious or   Event       Description of event                  Review findings                       Recommendations/actions                   Follow-up
  sentinel    code

  Sentinel     4B     Death of a baby following       Review underway.                       Report awaited.
                      emergency caesarean section.

  Serious      4B     Mother transferred to           Report completed. The patient had      A comprehensive handover be provided to
                      Christchurch by ambulance       been medically cleared for ambulance   appropriate CDHB staff for all maternity related
                      following birth was suffering   transfer without escort. While it      transfers. To support the process for mothers
                      from eclampsia on arrival.      appears that a clear process for       post delivery, a guideline be developed based
                                                      assessment and transfer occurred in    upon the current document ‘Guidelines for
                                                      this instance, there are no written    transfer of Maternity Care, Secondary –
                                                      guidelines regarding transfer of       Tertiary’, this to include guidance as to when a
                                                      mothers post delivery, nor guidance    midwife escort is appropriate.
                                                      around when a midwife escort is
                                                      appropriate.




                                                                                   Summary of DHB Serious and Sentinel Event Report 2010/11             79
                                                                                                                            West Coast District Health Board


Serious or   Event       Description of event              Review findings                           Recommendations/actions                       Follow-up
 sentinel    code

 Sentinel     4G     Death of a baby (twin)     Review completed. Causal findings              The induction process for new medical
                     following emergency        around                                          staff is reviewed and adjusted to ensure
                     caesarean section.                                                         there is suitable orientation to the facilities,
                                                   the need for a more
                                                                                                support services and to the likely impact of
                                                    comprehensive programme of
                                                                                                these on clinical practice
                                                    adjustment and orientation for
                                                    Obstetric Specialists to the rural         Ensure best evidence guidelines specific
                                                    environment,                                to the WCDHB are developed,
                                                                                                disseminated and available within the unit
                                                   the need for a local guideline for
                                                                                                on;
                                                    the management of twins to assist
                                                    staff when unexpected events                      electronic fetal monitoring         -
                                                    occur,                                              including mention that where
                                                                                                        continuous fetal monitoring is
                                                the absence of multidisciplinary                        indicated but unable to be
                                                training in Greymouth to facilitate                     obtained, Fetal Scalp Electrode
                                                communication between disciplines in                    (FSE) should be used
                                                complex clinical situations - may have
                                                                                                      the management of twin labour
                                                resulted in staff not effectively sharing
                                                                                                        and delivery – including delivery in
                                                their knowledge of local procedures,
                                                                                                        theatre for all twins
                                                not questioning decision making nor
                                                suggesting the use of additional               A    course     specifically to improve
                                                procedures/equipment.                           management of obstetric emergencies is
                                                                                                run at the WCDHB as a way of improving
                                                                                                multidisciplinary    teamwork   between
                                                                                                Obstetricians, Midwives, Anaesthetists,
                                                                                                Duty Nurse and Midwife Managers etc
                                                                                            That consideration is giving to transferring
                                                                                            women with multiple pregnancies to a tertiary
                                                                                            centre at an appropriate gestational age.




                                                                                 Summary of DHB Serious and Sentinel Event Report 2010/11                 80
                                                                                                                              West Coast District Health Board


Serious or   Event       Description of event                   Review findings                           Recommendations/actions                 Follow-up
 sentinel    code

 Sentinel     6      Inpatient fall sustaining a     Review completed. A family member           Clear guidelines are to be developed to assist
                     broken hip. The patient later   who was visiting the patient raised the     staff discuss and clarify the involvement of
                     died.                           bed rails and left the bedside without      family when visiting, and the need to notify
                                                     notifying ward staff enabling the patient   staff of departure.
                                                     unobserved to climb out of bed, fall to
                                                     the floor and fracture his neck of
                                                     femur.                                      Falls risk assessments must be carried out for
                                                                                                 all patients on admission and where
                                                     While known high falls risk, no formal
                                                                                                 appropriate during the course of the
                                                     assessment of same documented in
                                                                                                 admission.
                                                     file.

 Sentinel     11     Patient with known epilepsy     Review completed – not a clinical
                     was found dead while awaiting   incident. Died of natural causes.
                     discharge.
                                                     [Information provided after
                                                     publication of SSE report, so this
                                                     incident is included in the overall
                                                     data.]




                                                                                     Summary of DHB Serious and Sentinel Event Report 2010/11              81
                                                                                                                                Canterbury District Health Board



Canterbury District Health Board
www.cdhb.govt.nz

 Serious or   Event      Description of event                 Review findings                            Recommendations/actions                    Follow-up
  sentinel    code

Sentinel       4B     Patient diagnosed with a    Information relating to the recent           Information on the recent use of drugs which        Completed.
                      stroke. Clot-dissolving     administration of drugs that also affect     affect blood clotting must be included on forms
                      therapy was administered    blood clotting was not available at the      and protocols used to assess the risk against
                      and the patient later       time the decision was made to                benefits of clot dissolving therapy in individual
                      suffered a brain            administer the clot-dissolving therapy.      patients.
                      haemorrhage and died.
                                                                                               Amend the discharge summary to include a
                                                                                               section for documenting specific drugs that
                                                                                               affect blood clotting that are administered to
                                                                                               inpatients.

Serious        4B     Patient received a higher   Separate prescriptions for the dose of       All treatments to the same or adjacent sites are    Action
                      than intended dose of       radiation were written for each side of      to be prescribed on the same prescription form.     under way.
                      radiotherapy treatment      the limb. This resulted in the exit doses
                                                  of radiation not being taken into account,
                                                  leading to a higher than intended dose
                                                  being delivered to the skin.

Serious        4B     Planned antibiotic          Root Cause Analysis under way.               Report awaited.
                      treatment to be given in
                      labour was not
                      administered. Baby
                      developed septicaemia and
                      became unwell.

Sentinel       4B     Baby unwell at delivery,    Root Cause Analysis under way.               Report awaited.
                      transferred to NICU and
                      later died.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11              82
                                                                                                                             Canterbury District Health Board


Serious or   Event      Description of event                   Review findings                           Recommendations/actions                 Follow-up
 sentinel    code

Sentinel      4D     A planned removal of the      Root cause analysis review completed.       Report in draft.
                     gall bladder was
                     complicated by a bowel
                     perforation. The patient
                     died unexpectedly 11 days
                     later.

Serious       4D     Patient’s wound drains        Patient was cared for in another surgical   Continue review of surgical bed requirements      Action
                     were removed prematurely,     specialty ward post-operatively where       and ensure the issues surrounding this event be   under way.
                     requiring a return to the     staff were less familiar with the post-     made known to the group reviewing surgical bed
                     operating theatre to have     operative care of breast surgery            requirements.
                     the drains reinserted under   patients.
                     general anaesthetic.
                                                   Instructions with regards to drain
                                                   removal were misunderstood.

Serious       5      Concentrated potassium        Incorrect administration of concentrated    No concentrated potassium will be held in any     Action
                     was administered as a         potassium.                                  clinical area.                                    under way.
                     bolus without resultant
                     harm.

Serious       8      Mental health inpatient       No preventable causal factors identified.   No recommendations.
                     absconded from care.
                     Potential for serious harm.

Serious       11     A severe (stage 4) pressure   Timing issues/delays occurred in the        All staff to complete revision of pressure area   Actions
                     injury developed during in-   reporting of the pressure injury and        assessment and prevention, including the use of   under way
                     patient episode.              ordering and provision of pressure-         pressure-relieving equipment.
                                                   relieving equipment.

Serious       11     A severe (stage 4) pressure   Timing issues/delays occurred in the        All staff to complete revision of pressure area
                     injury developed during       reporting of the pressure injury and        assessment and prevention, including the use of
                     inpatient episode.            ordering and provision of pressure-         pressure relieving equipment.
                                                   relieving equipment.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11         83
                                                                                                                                  Canterbury District Health Board


Serious or   Event      Description of event                   Review findings                             Recommendations/actions                     Follow-up
 sentinel    code

Serious       4D     A baby unwell at delivery     Despite many advances there remain            All women who are admitted to the maternity           Actions
                     later died.                   significant limitations with respect to the   ward for observation in the antenatal period          under way.
                                                   usefulness of ultrasound to predict           should be reviewed by an obstetric SMO on a
                                                   actual or imminent fetal compromise in        regular basis, ideally at least twice per week.
                                                   late pregnancy. This meant that the           The SMO must oversee care and formulate a
                                                   degree of antenatal compromise in this        coherent management plan and where
                                                   pregnancy was not recognised.                 appropriate communicate this to colleagues.
                                                   There was inadequate senior medical           In all cases where there are suspected maternal
                                                   officer (SMO) supervision of care. No         or fetal risk factors the decision for induction of
                                                   one SMO took responsibility for making        labour should be reviewed by an obstetric SMO.
                                                   a plan of management and                      The current maternity unit ‘Induction of Labour’
                                                   communicating the history and that plan       guideline will require review and amendment to
                                                   to the team on Birthing Suite.                reflect this recommendation.
                                                   There was no systematic obstetric SMO         SMOs should be involved at all steps of the
                                                   involvement in the induction process.         induction process where such additional risk
                                                   More senior obstetric opinion may have        factors are identified and a logical plan for
                                                   increased the awareness of risk and the       induction should be made by the obstetric SMO.
                                                   priority for rapid delivery once events
                                                                                                 A classification system for caesarean section
                                                   unfolded.
                                                                                                 which leaves no room for misinterpretation of
                                                   The current classification system for         urgency is required. The classification system
                                                   caesarean section does not provide a          will indicate the need for a member of the
                                                   sufficiently clear indication either of       neonatal team experienced in advanced
                                                   urgency or of clinical indication. As a       resuscitation.
                                                   result, neonatal staff and some staff in
                                                                                                 On introduction of this change, appropriate staff
                                                   Birthing Suite and Birthing Suite Theatre
                                                                                                 education should take place.
                                                   were not certain of the urgency
                                                   regarding delivery nor the reason for         Development of a guide for new neonatal RMOs
                                                   that urgency. This may have increased         on requesting anaesthetic support.
                                                   the interval from decision to delivery and
                                                   may have compromised staffing at              Improved processes for neonatal resuscitation
                                                   baby’s resuscitation.                         training.

 Serious      6      Inpatient fall sustaining a   The Clinical Board is providing a leadership role to progress work in falls prevention and management with
                     broken hip.                   the vision of having zero harm from falls. All SAC 1 & 2 falls are subject to a root cause analysis (RCA)




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11               84
                                                                                                                                  Canterbury District Health Board


Serious or   Event      Description of event                   Review findings                             Recommendations/actions                      Follow-up
 sentinel    code
                                                   review, the learnings from which contribute to the overall Clinical Board-led falls initiative. Key activities
 Serious      6      Inpatient fall sustaining a
                                                   and initiatives in this area include:
                     broken toe.
                                                      a fall event notification sticker implemented across the hospitals to make falls more visible in the
 Serious      6      Inpatient fall sustaining a       clinical record and reinforce the heightened ‘falls risk’ of individual patients to staff
                     broken hip.
                                                      patient safety crosses and ward location maps used to display information regarding the number of
                                                       falls in an area. These tools help to heighten awareness of the impact of falls
 Serious      6      Inpatient fall sustaining a
                     broken arm.                      Patient Safety Walk Rounds have commenced. These provide an opportunity for front-line staff to
                                                       have conversations with Clinical Board members about their concerns, successes and ideas for
 Serious      6      Inpatient fall sustaining a       improvement regarding patent safety
                     broken arm.
                                                      an intranet page providing information for staff on the Clinical Board-led patient falls initiative
 Serious      6      Inpatient fall sustaining a      the Canterbury Clinical Network Transitional Leadership Board (TLB) has approved funding over the
                     broken hip.                       next two years for community-based falls prevention programme delivery. This forms a component of
                                                       a wider health system initiative; ‘Moving Towards Zero Harm – a whole-of-system approach to falls
 Serious      6      Inpatient fall sustaining a       prevention’ being championed by the CDHB Clinical Board. The funding provided by the TLB will be
                     broken hip.                       utilised for the provision of the Otago Exercise Programme (OEP) and Stay on Your Feet programme.
                                                       Funding models and delivery currently being considered.
 Serious      6      Inpatient fall sustaining a
                     broken hip.

 Serious      6      Inpatient fall sustaining a
                     broken clavicle (collar
                     bone).

 Serious      6      Inpatient fall sustaining a
                     broken hip.

 Serious      6      Inpatient fall sustaining a
                     dislocated hip.

 Serious      6      Inpatient fall sustaining a
                     broken hip.

 Serious      6      Inpatient fall sustaining a
                     broken hip.




                                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11                     85
                                                                                                        Canterbury District Health Board


Serious or   Event      Description of event        Review findings                   Recommendations/actions               Follow-up
 sentinel    code

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell sustaining a
                     severe skin tear.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken wrist.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Sentinel     6      Inpatient fell, sustaining a
                     head injury. Patient’s
                     condition deteriorated and
                     they died three days later.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.



                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11      86
                                                                                                         Canterbury District Health Board


Serious or   Event      Description of event         Review findings                   Recommendations/actions               Follow-up
 sentinel    code

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     head injury (small volume
                     subarachnoid
                     haemorrhage).

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     laceration requiring
                     stitches.

 Serious      6      Inpatient fell, sustaining a
                     broken arm.

 Serious      6      Inpatient fell, sustaining a
                     laceration requiring
                     stitches.

 Serious      6      Inpatient fell, sustaining
                     broken hip.

 Serious      6      Inpatient fell, with
                     worsening of an existing
                     brain haemorrhage.
                     Deterioration continued and
                     patient died five days later.

 Serious      6      Inpatient fell, sustaining a
                     broken hip.




                                                                       Summary of DHB Serious and Sentinel Event Report 2010/11      87
                                                                                                        Canterbury District Health Board


Serious or   Event      Description of event        Review findings                   Recommendations/actions               Follow-up
 sentinel    code

 Serious      6      Inpatient fell, sustaining a
                     broken hip.

 Serious      6      Inpatient fell, sustaining
                     broken hip.

 Serious      6      Inpatient fell, sustaining a
                     broken elbow.




                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11      88
                                                                                                                           South Canterbury District Health Board



South Canterbury District Health Board
www.scdhb.health.nz

 Serious or   Event    Description of event                   Review findings                    Recommendations/actions                       Follow-up
  sentinel    code

  Serious      5      Patient prescribed            Correct medication reconciliation      Standardisation of process and              Action plan developed
                      incorrect medications         process was not followed.              confirmation requirements for               and monitored. All action
                      resulting in a significant                                           medication reconciliation with              points progressing with
                      deterioration in patient’s                                           community and hospital pharmacists          planned roll-out of
                      physical condition. The                                              established.                                medicines reconciliation
                      patient made a full                                                                                              across all inpatient
                      recovery.                                                                                                        services in 2011.

  Serious      6      Resident fall in hospital     Independently mobile resident          Falls Prevention and Management Audit was completed in the third
                      level dementia unit,          sustained a fractured hip. Fracture    quarter 2010/11 following the introduction of the Falls Prevention and
                      resulting in fractured hip.   surgically repaired.                   Management Programme on 20 September 2010.
                                                                                           Overall there was a high level of compliance with completing the falls
  Serious      6      Patient fall with no          Falls risk assessment completed and    action plan once a patient had been identified as a falls risk.
                      obvious injury until two      fall prevention plan in place.
                      days later when swelling                                             A Falls Champions Group has been established. This Group are
                      and X-ray revealed a                                                 currently working to identify key messages to feed back to staff to
                      fractured leg (tibial                                                highlight risk of falls.
                      plateau).
                                                                                           A pamphlet for patients/family/whanau to explain the programme is
                                                                                           being developed.
  Serious      6      Patient fall resulting in     Falls risk assessment completed on
                      serious wound to leg.         admission and falls prevention plan
                                                    in place, including requirement for
                                                    supervision when mobilising.
                                                    Patient attempted to mobilise
                                                    independently.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11               89
                                                                                                                       South Canterbury District Health Board


Serious or   Event    Description of event                   Review findings                      Recommendations/actions                 Follow-up
 sentinel    code

 Serious      6      Patient fall resulting in    Falls risk assessment completed
                     fractured ribs, pelvis and   indicating a high falls risk. Falls
                     sacrum.                      prevention plan in place – including
                                                  use of a sensor mat.
                                                  Sensor mat not plugged in when fall
                                                  occurred.

 Serious      6      Patient found on floor       Falls risk assessment not completed
                     and subsequent review        on admission.
                     of X-ray showed multiple
                     broken ribs.

 Serious      6      Resident fell, sustaining    Falls risk assessment completed,
                     a fractured hip.             indicating high risk of falls and fall
                                                  prevention plan in place.
                                                  Resident mobilised without walking
                                                  frame and fell.
                                                  Fracture surgically repaired.

 Serious      6      Resident fell, sustaining    Falls risk assessment completed
                     a fractured hip.             indicating high risk of falls and fall
                                                  prevention plan in place.
                                                  Resident mobilised without walking
                                                  frame and fell.
                                                  Fracture surgically repaired.

 Serious      6      Patient fell from bed.       Falls risk assessment completed on
                     No obvious head injury       admission and falls prevention plan
                     noted on examination.        in place; however, management
                     Two hours later patient      guidelines relating to monitoring
                     found to be                  patients following a fall were not
                     unresponsive and             followed resulting in a failure to
                     subsequently died.           detect the deteriorating patient.
                     Referred to Coroner.




                                                                                           Summary of DHB Serious and Sentinel Event Report 2010/11       90
                                                                                                                    South Canterbury District Health Board


Serious or   Event    Description of event                 Review findings                     Recommendations/actions                 Follow-up
 sentinel    code

 Serious      6      Patient fell, sustaining a   Falls risk assessment completed on
                     fractured arm.               admission and falls prevention plan
                                                  in place.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11       91
                                                                                                                                     Southern District Health Board



Southern District Health Board
www.southerndhb.govt.nz


 Serious or   Event   Description of event                Review findings                   Recommendations/actions                          Follow-up
  sentinel    code

Sentinel       2      Voluntary patient          No clear single point of contact for   A single contact point for family with   Risk Management Working Group
                      committed suicide          the patient’s family and rostering     a member of staff likely to be           formed to review the service
                      while on overnight         of nursing staff means the primary     consistently available.                  approach to risk assessment and
                      leave.                     nurse is only intermittently                                                    management of clinical risk.
                                                                                        Review of the current risk
                                                 available.
                                                                                        documentation practices.                 A draft revised treatment plan for
                                                 The long-term high risk of suicide                                              inpatient areas is currently under
                                                                                        Discussion take place between
                                                 for this patient was not                                                        consultation, part of which aims to
                                                                                        Southern DHB mental health
                                                 documented. Only short-term                                                     improve the recording and follow-
                                                                                        services and the NZ Police about the
                                                 clinical risk was regularly noted.                                              up of clinical risk observations and
                                                                                        removal of firearms licences during
                                                                                                                                 regularly changing leave status.
                                                 Although the patient’s firearms        significant episodes of depression
                                                 were removed from his                  and the pathway to reinstatement of
                                                 possession he was able to use his      firearms licences when full recovery
                                                 firearms licence to purchase a         has occurred.
                                                 new gun.

Serious        6      Inpatient fall resulting   Falls prevention strategies were       All reasonable steps had been taken      Staff are now more aware of the
                      in laceration to inner     appropriate and supervision            to keep the patient safe while           hazard and will consider the
                      forearm.                   during activity was of a high          permitting return to maximum             potential risk when assisting or
                                                 standard.                              independence.                            supervising patients’ mobility in
                                                                                                                                 areas where linen trolleys are
                                                                                                                                 located.

Sentinel       2      Inpatient suicide.         Investigation under way.




                                                                                          Summary of DHB Serious and Sentinel Event Report 2010/11               92
                                                                                                                                     Southern District Health Board


Serious or   Event   Description of event              Review findings                    Recommendations/actions                           Follow-up
 sentinel    code

Sentinel      3      Retained central line    This was a complex insertion            As the task is unable to be changed,
                     guide wire following a   which required two central line         the intensive care unit has educated
                     complex central line     packs to be used, resulting in the      all the staff who might be involved in
                     insertion, requiring     first wire accidentally being left in   any central venous line insertion to
                     removal in radiology.    place.                                  maintain vigilance to ensure that the
                                                                                      wire is removed – particularly if two or
                                              The standard technique for
                                                                                      more kits are used.
                                              inserting central lines is the
                                              ‘Seldinger’ technique which is a
                                              well-established procedure in
                                              clinical practice used to introduce
                                              catheters, probes, electrodes, etc.
                                              into vessels.

Serious       3      Retained surgical        No policy in place within the           Requirement that all medical officers      Cardiology Dept now has radio
                     swab following a         setting by which the attending          undertaking pacemaker implantation         opaque gauze and all standard
                     pacemaker insertion.     doctor is required to advise the        (or any other procedure involving an       gauze has been removed.
                     Swab found during        scrub nurse/circulating nurse that      open wound) to advise the scrub
                                                                                                                                 Swabs (and all other equipment
                     another surgical         an open wound is/has been               nurse/circulating nurse of an
                                                                                                                                 used) are counted and
                     procedure.               ‘packed’ with a gauze swab.             intention, or the act of, placing a
                                                                                                                                 documented as per the surgical
                                                                                      gauze swab (or any other temporary
                                              No policy within the setting                                                       count policy.
                                                                                      item) within the wound pocket.
                                              enabling and requiring an
                                                                                                                                 Patient X-rayed during procedure
                                              instrument, sharps and/or a swab        Implement the Main Operating
                                                                                                                                 which    would   highlight   any
                                              count to be undertaken when an          Theatre Surgical Count Policy in this
                                                                                                                                 remaining gauze.
                                              open wound procedure is                 area.
                                              undertaken.
                                                                                      All swab material to contain a radio
                                              The gauze swabs used in the             opaque marker.
                                              cardiology laboratory are not
                                                                                      When a surgical wound site
                                              radio-opaque and therefore
                                                                                      demonstrates signs of infection,
                                              cannot be identified upon
                                                                                      and/or inflammation, and/or oedema,
                                              ultrasound or X-ray imaging.
                                                                                      multi-view X-rays of the site are
                                              The potential for a retained            performed for the purpose of
                                              product producing an                    excluding the possibility of retained
                                              inflammatory response does not          equipment.
                                              have a mechanism for
                                              investigatory escalation.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11                  93
                                                                                                                                 Southern District Health Board


Serious or   Event   Description of event              Review findings                  Recommendations/actions                          Follow-up
 sentinel    code

Sentinel      4B     Delay in resuscitation   The basic adult collapse algorithm    Consider staff working a high            Resuscitation Committee continue
                     procedure that may or    was followed correctly up to the      proportion of night shifts be required   to audit the arrest team on a
                     may not have             point of early connection to a        to undertake CPR certification at        quarterly basis to monitor for
                     contributed to patient   defibrillator.                        level 5 or 6.                            further development opportunities.
                     death.
                                              Night staff to have further CPR       Review of handover practises outside
                                              training on working with smaller      of supervised handovers.
                                              teams.
                                                                                    Review of the patient watch
                                              No formal handover practice           requirements.
                                              outside of supervised handovers
                                                                                    Formal orientation to the role for
                                              for medical staff.
                                                                                    resuscitation team members.
                                              One RN had to supervise another
                                                                                    Telemetry request log is redesigned
                                              agitated patient on the ward which
                                                                                    and the existing telemetry documents
                                              prevented other tasks from being
                                                                                    are reviewed.
                                              completed.
                                              Resuscitation team were not
                                              aware of their roles in the arrest
                                              leading to no one taking charge.
                                              Difficulty obtaining telemetry
                                              reading from the patient.

Sentinel      4A     Misdiagnosis resulting   Infusion and subsequent               All patients presenting with severe      A hospital-wide patient safety alert
                     in patient developing    correction of low sodium level        low sodium (less than 115) are           has been distributed for learning
                     clinical complication    (hyponatremia) resulted in            admitted to ICU for controlled           purposes.
                     (osmotic myelinolysis)   osmotic myelinolysis.                 management.
                                                                                                                             Implementation of a new Food
                     requiring intensive
                                              Low sodium result was not initially   Review pro forma for hand writing of     Management System which aims
                     treatment and
                                              recognised.                           blood test results.                      to improve meal provision to
                     rehabilitation.
                                                                                                                             patients with specific dietary
                                              Meals low in sodium were not
                                                                                                                             requirements.
                                              provided as requested.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11                94
                                                                                                                                   Southern District Health Board


Serious or   Event   Description of event                Review findings                   Recommendations/actions                        Follow-up
 sentinel    code

Serious       6      Inpatient fall resulting   The falls prevention plan was          The use of falls alarms should be
                     in a fractured hip.        developed and followed to best         continued as long as a high risk of
                                                care for the patient.                  falls exists and their use can be
                                                                                       justified.
                                                Consideration was given to the
                                                residential context the patient was    Consideration should be given to the
                                                being discharged to and hence          purchase of hip protector pads to
                                                the falls alarm was discontinued       decrease the likelihood of a fall
                                                just prior to the fall.                resulting in a hip fracture.
                                                Protective hip pads, although not
                                                able to prevent the risk of falls,
                                                could minimise the risk of
                                                fractures resulting from falls.

Serious       4B     Management of              Investigation under way.
                     mother in labour in the
                     community requiring
                     urgent treatment.

Sentinel      11     Inpatient death            Possibility that the patient           Mental health staff to have education   Co-Existing Problems Working
                     subsequent to taking       obtained Methadone for                 from the community alcohol and drug     Group is meeting regularly and
                     Methadone obtained         recreational use while on              service about the high risks            attention is being given to the
                     illegally.                 approved ward leave.                   associated with recreational            development of a broad skill set
                                                                                       methadone use.                          among MH staff which will include
                                                Patient did not present with early
                                                                                                                               addiction issues.
                                                warning signs of Methadone             The Co-existing Problems Working
                                                toxicity, therefore patient was only   Group will consider the inclusion of
                                                observed every 30 minutes              methadone toxicity as a subject in
                                                overnight according to protocol.       the development of the upcoming
                                                                                       education.
                                                                                       A fact sheet on methadone toxicity
                                                                                       be developed for patients identified
                                                                                       as current or potential illicit
                                                                                       methadone users.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11             95
                                                                                                                                 Southern District Health Board


Serious or   Event   Description of event                Review findings                   Recommendations/actions                      Follow-up
 sentinel    code

Serious       6      Inpatient fall resulting   The falls prevention programme is      Implementation of falls prevention    A preliminary falls prevention
                     in fractured ankle         currently under development for        programme in mental health units.     education session has been
                     requiring surgery.         mental health units.                                                         provided to staff.
                                                Consideration of falls risk and the
                                                physical environment were not
                                                included in the patient’s care plan.

Serious       6      Inpatient fall resulting   Patient was assessed thoroughly        No corrective actions could be        Falls    Prevention  Programme
                     in fractured hip.          and did not meet the criteria for      identified as patient, who felt       Audits continue to ensure the
                                                provision of a falls alarm.            confident to do so, mobilised         assessment      documents    are
                                                                                       independently against                 capturing those at-risk patients
                                                No evidence of medical instability
                                                                                       recommendations from staff.           appropriately.
                                                or change in medication regime
                                                that could have contributed to this
                                                patient being a falls risk.
                                                A contributing factor may have
                                                been long-standing back pain
                                                which may have affected patient’s
                                                balance and fall protection
                                                responses.

Sentinel      11     Patient death in the       The patient’s emergency plan had       Purchase of back-up battery power     Three power stations have now
                     community resulting        been established in line with          stations to supplement current non-   been purchased for use.
                     from non-invasive          current national and Australian        invasive ventilation machines.
                     ventilation machine        practice.
                     ceasing to function
                                                Both the oxygen concentrator and
                     during power failure.
                                                ventilator were functional with
                                                working alarm systems.
                                                No consistent provision of an
                                                uninterrupted power supply
                                                provided for non-invasive
                                                ventilation equipment supplied for
                                                home use.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11          96
                                                                                                                                   Southern District Health Board


Serious or   Event   Description of event                Review findings                  Recommendations/actions                          Follow-up
 sentinel    code

Serious       6      Inpatient fall resulting   Falls prevention risk planning was    Documentation standards and              Ongoing audit of the falls
                     in fractured knee.         not completed prior to the patients   expectations to be reinforced to staff   prevention programme to ensure it
                                                fall; however, the physiotherapist    via the charge nurse managers and        is being 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 staff    The education session focused on
                     contamination of a         discarded at the end of the duty      to 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 staff
                                                                                      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 under way.
                     an alleged assault
                     occurred.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11               97
                                                                                                                             Southern District Health Board


Serious or   Event   Description of event               Review findings                   Recommendations/actions                   Follow-up
 sentinel    code

Sentinel      4F     Delayed access to         Investigation under way.
                     emergency treatment
                     in remote site prior to
                     urgent transfer
                     resulting in patient
                     death.

Serious       3      Retained surgical         Investigation under way.
                     instrument (clamp)
                     following gastric
                     bypass surgery
                     requiring subsequent
                     surgical removal.

Sentinel      4A     Misdiagnosis resulting    The patient’s presenting               A process to enable consultant
                     in patient discharge      complaint was of back pain.            involvement in decision making
                     and subsequent death      Misdiagnosis and discharge             regarding discharge from the
                     due to rupture of major   occurred despite thorough              Emergency Department (ED).
                     abdominal artery          examination.
                                                                                      Establish a process to ensure timely
                     (aorta).
                                               Delay in radiology reporting which     review of X-ray findings for ED
                                               may have identified the condition.     patients.
                                               Current back pain proforma does        Consider adding rupture of
                                               not include rupture of abdominal       abdominal artery to the current
                                               aorta as part of the diagnosis as it   proforma with guidance on potential
                                               is a rare cause.                       for misdiagnosis.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11       98
                                                                                                                                   Southern District Health Board


Serious or   Event   Description of event                Review findings                   Recommendations/actions                        Follow-up
 sentinel    code

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 audit 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 usual prescriber.
                                                                                       Nursing staff are to administer liquid
                                                                                       medications only if prescribed in
                                                                                       milligrams.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11            99
                                                                                                                                Southern District Health Board


Serious or   Event   Description of event               Review findings                 Recommendations/actions                         Follow-up
 sentinel    code

Sentinel      4D     Cardiac arrest of          Equipment became disconnected       Anaesthetic Specialist, Registrar and   At least once yearly educational
                     ventilator-dependant       during transfer.                    Technician education regarding the      visits as part of departmental
                     patient during MRI                                             equipment utilised in this and other    teaching to maintain familiarisation
                                                The incident was well managed
                     scan.                                                          environments in Radiology.              with this environment.
                                                with a successful outcome.
                                                                                    Continuing ongoing advanced life
                                                                                    support education be undertaken by
                                                                                    all Anaesthesia and ICU staff.

Serious       6      Inpatient fall resulting   Investigation under way.
                     in fracture of pelvis.

Serious       6      Inpatient fall resulting   Investigation under way.
                     in fractured knee.


Sentinel      4F     Death of a child with      Baseline oxygen saturations when    Children with chronic cardio-
                     complex underlying         patient was well were not           respiratory conditions should have
                     health conditions,         available for reference.            baseline oxygen saturations recorded
                     which may or may not                                           at intervals when well.
                                                Resuscitation status was not
                     have been prevented
                                                clearly documented.                 Children with complex life-
                     by earlier admission to
                                                                                    threatening medical problems
                     the Intensive Care         Paediatric Early Warning Scoring
                                                                                    presenting with acute illness should
                     Unit.                      System (PEWS) not currently in
                                                                                    have their resuscitation status
                                                use, but is under development for
                                                                                    reviewed in discussion with
                                                use in South Island DHBs.
                                                                                    family/whanau and clearly
                                                                                    documented.
                                                                                    PEWS trial to take place on the
                                                                                    children’s ward.

Sentinel      4D     Inadvertent                Investigation under way.            In the interim an organisational risk
                     misplacement of a                                              alert has been circulated to inform
                     nasogastric tube                                               staff of the potential risks of this
                     resulting in patient                                           procedure.
                     death.




                                                                                      Summary of DHB Serious and Sentinel Event Report 2010/11             100
                                                                                                                                Southern District Health Board


Serious or   Event   Description of event                Review findings                  Recommendations/actions                          Follow-up
 sentinel    code

Serious       6      Inpatient fall resulting   Investigation under way.
                     in fractured hip.

Sentinel      4C     Delay in monitoring        Root cause analysis being             Recommendations not finalised at      In progress.
                     and response to the        undertaken.                           time of reporting.
                     coagulation status of
                     the patient may have
                     contributed to bleed in
                     brain (subarachnoid
                     haemorrhage) and
                     patient death.

Serious       4A     Delayed radiological       Diagnostic error highlighted where    Departmental audits undertaken.       Completed.
                     diagnosis resulting in     spinal lesion missed on CT scan
                     paralysis.                 undertaken. Not identified until
                                                subsequent MRI taken to
                                                diagnose back pain and leg
                                                weakness.
                                                Full disclosure and apology to
                                                patient and family. ACC
                                                treatment injury completed.

Serious       4E     Delay in receiving         Referral prioritised incorrectly as   Review of Medical Imaging referral    Completed.
                     radiological diagnosis     non-urgent.                           process completed.
                     leading to disease
                                                Examination completed 10              Recommendations for improvement
                     progression of bladder
                                                months post referral.                 currently being implemented.
                     cancer.
                                                                                      Wait list managed back within
                                                                                      guidelines of six to seven weeks.

Serious       4E     Delay in diagnosis of      Root cause analysis undertaken        Review medical staff orientation,     In progress.
                     cancer.                    finding issues with the handling of   Explore system to flag all abnormal
                                                abnormal scan results.                results.




                                                                                        Summary of DHB Serious and Sentinel Event Report 2010/11         101
                                                                                                                                   Southern District Health Board


Serious or   Event   Description of event                Review findings                   Recommendations/actions                            Follow-up
 sentinel    code

Serious       6      Inpatient fall resulting   Patient mobilising with distant        Falls programme introduced.             Completed.
                     in fractured hip.          supervision following clinical
                                                assessment in preparation for
                                                discharge, and fell.

Serious       8      Patient expected to be     Miscommunication between               Review and update with Police to        Completed.
                     assessed absconded         Police and Duly Authorised             ensure that assessment happens in
                     while awaiting Mental      Officer resulting in delay of          the most appropriate setting. Patient
                     Health Act                 assessment until the following         subsequently assessed with no
                     assessment.                day.                                   adverse outcomes.

Serious       4C     Patient developed          Risk not adequately assessed           Review risk assessment and              In progress.
                     severe pressure sore.      and documented to facilitate           monitoring.
                                                optimal treatment.
                                                                                       Review communication between
                                                Poor communication between             clinical teams.
                                                community and hospital in a
                                                                                       Formation of Pressure Injury and
                                                compromised patient resulting in
                                                                                       Prevention Team (PIPI) has been
                                                severe pressure injuries following
                                                                                       actioned.
                                                a surgical procedure and
                                                subsequent short hospital stay.
                                                Underlying development of
                                                pressure sores in the community
                                                due to 28 days sitting and
                                                sleeping in chair with feet on foot
                                                rest. Theatre/recovery time added
                                                significantly to the pressure injury
                                                on heals – blister noted day two
                                                post-discharge.

Serious       4A     Administration of          Treatment commenced based on           Future decisions will follow new        Completed.
                     medication resulting in    patients presenting symptoms           clinical protocol.
                     termination of a           and diagnostic information
                     potentially viable         available at the time leading to
                     pregnancy.                 misdiagnosis of an ectopic
                                                pregnancy.




                                                                                         Summary of DHB Serious and Sentinel Event Report 2010/11           102

				
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