Docstoc

Incident Report Incident - DOC

Document Sample
Incident Report Incident - DOC Powered By Docstoc
					                                                                  Incident Report
                                                                  17/11/06 - 22/01/07


 Datix Handle Director Location Severity Detail   Incident Description                     Action taken                     Action taken (Investigation)
    ID r      ate      (type)                     date

Directorate: Head Injury Unit

  973 JAC      HIU      CLIVE    MODER Abuse    03/12/06 when myself and the other staff   left the place for a minute to   Reported to bleepholder at 07.30 Advised to see
                                       etc of            with me were washing one of       get relieve from the shock       GP and support by bleepholder to JM given. Q/N
                                       Staff by          the patient, who was wet on the   and the pain.then gone back      phoned in sick at 11.00 and advised to see GP
                                       patients          bed, without any provocation he   to the patient and just pass     again by bleepholder. ONC contacted on monday
                                                         was kicked on my chest and on     the articles which needed to     am. contacted Q/N -will be off sick for another
                                                         the stomach region.               the other staff.                 night. Back at work at the weekend-will work in
                                                                                                                            another area (HDU). Debreifing arranged for Q/N
                                                                                                                            to be given by Night sister on sunday night. Q/N
                                                                                                                            appt. on Monday cancelled and saw GP
                                                                                                                            tuesday.ONC confirmed debrifing on thursday to
                                                                                                                            Q/N-pain now better.
                                                                                                                            Monday-ONC e-mailed managersand Primary
                                                                                                                            team regarding incident and CQW team
                                                                                                                            discussed about care to this patient and ways to
                                                                                                                            reduce kicking. Coodinator and Psychologist
                                                                                                                            contacted and Primary meeting arranged
                                                                                                                            urgently-happened on tuesday 15.12.06.
                                                                                                                            guidelines reviewed and agreed by the team.
                                                                                                                            Request for patient to have regular imput by the
                                                                                                                            psychologist.
                                                                                                                            11/12/06-debreifing occurred. Q/N seen
                                                                                                                            ONC-incident discussed. For occupational health
                                                                                                                            appt. and to see psychologist to set programmne
                                                                                                                            to slowwly introduce to patient. Q/N clear not to
                                                                                                                            care fro patient at present time unless in am
                                                                                                                            emengency. EAP offered to Q/N.
                                                                                                                            21.12.06-Q/N working well in other areas. To
                                                                                                                            arrange time with pysologist in the New Year to
                                                                                                                            develop programmne of control re-introduction.
                                                                                                                            To have follow up debrief.
                                                                                                                            15.01.07-follow up with Q/N by ONC. For
                                                                                                                            Occupaital health appt. on 25.01.07. Remains
                                                                                                                            some soreness. Discussed again arrange time

Printed on 23 January 2007 by Anne Fahey                                                                                                                    Page 1
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                        Action taken                     Action taken (Investigation)

                                                                                                                                 with psychologist to have control reintroduction to
                                                                                                                                 patient for limited activities. For Q/N to agree a
                                                                                                                                 day for a day shift. For follow up debreif with
                                                                                                                                 Night Sister. Ongoing support.

 1010 JAC     HIU      HIUGEN MODER Abuse    15/01/07 NA went to patient to introduce           Patient was left alone and as    Q/N discussed and showed guidelines regarding
                                    etc of            herself and explain what she              told that it was wrong to kick   the patient to the N/A. N/A working with a
                                    Staff by          was going to do (a wash), she             out.. As patient had just had    RNHRD staff who was the lead out of the 2 and
                                    patients          had read the guidelines so was            his medications, it was          taking the main role in communicating with the
                                                      aware of how to approach,                 decided to leave him until       patient-as guidelines. No obvious reason for the
                                                      (he bed was already raised as             they took effect                 aggressive kick. N/A removed immediately and
                                                      S/N had just given him his                                                 any injuries checked for. Graze on arm noticed.
                                                      drugs.)                                                                    Patient wearing socks and no body fluids around.
                                                      Patient immediately kicked out                                             Checked with Occupational Health no further
                                                      at NA and left a mark on her left                                          treatment needed. Advice given to N/A to
                                                      fore-arm                                                                   observed grauze and any signs of deterioration to
                                                                                                                                 report and seek medical advice. Debriefing given
                                                                                                                                 to the N/a by experienced Q/N from CQW. ONC
                                                                                                                                 contacted N/A next day (16) as support and
                                                                                                                                 further debreifing.
                                                                                                                                 16.01.07--Concerns from ONC regarding
                                                                                                                                 difficulty in maintaining staff safety and reducing
                                                                                                                                 the risks due to patients complex problems.
                                                                                                                                 Review again of the strategies in place. Primary
                                                                                                                                 Team meeting took place 11.01.07 due
                                                                                                                                 recognisation of an increase of unpredicatabilty
                                                                                                                                 from the patient. Communication through blinking
                                                                                                                                 and eye contacted worked on. Patient had
                                                                                                                                 session with coordinator and pyschologist
                                                                                                                                 discussing his behaviour problems-done in a
                                                                                                                                 manner appriopriate for the patients ability. Team
                                                                                                                                 discussed issues with ONC on thursday and
                                                                                                                                 firday (11 &12). Some alterations discussed such
                                                                                                                                 as changing bedspaces. Issue regarding this
                                                                                                                                 patient raised with HIU management. ONC
                                                                                                                                 approached Professional Nursing lead for the
                                                                                                                                 Trust for issues regarding staff safety. Discussion
                                                                                                                                 with the area team of CQW held at their monthly
                                                                                                                                 meeting on 16/01/07 on ways to manage this

  986 JAC     HIU      SECOND MINOR        Abuse    20/12/06 patient kicking violently at       requested patient to stop        Discussed by ONC with Q/n on days and with Q/n
                                           etc of            nursing staff whilst attempting to kicking made safe and            on nights involved in situation. Debriefing
Printed on 23 January 2007 by Anne Fahey                                                                                                                           Page 2
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail       Incident Description                    Action taken                    Action taken (Investigation)

                                           Staff by            change patients incontinence   nurses withdrew from            done-suggestions on improving on managing
                                           patients            pad.                           bedside. patient smirked at     behaviour-some comments to go back to Primary
                                                                                              nursing staff as nurses         team. Coordinator and Pyschogolist aware.
                                                                                              attempted to follow             Discussion on catheter to reduce incontinence
                                                                                              guidelines.                     and frequent care given to be done with patient
                                                                                                                              and Primary nurse and pyschogolist. Q/n to
                                                                                                                              check that patients sacrum not sore or boken as
                                                                                                                              appears to be sensitive and part of the incident.
                                                                                                                              Noticed that patient has 2 different types of
                                                                                                                              kicks-one 'stamping' and one kicking out to
                                                                                                                              staff-is in the guidelines. also patients facial
                                                                                                                              expression can indiate patients mood.
                                                                                                                              For N/a on nights to have debreifing by Night
                                                                                                                              sister.
                                                                                                                              22/12/06-discussed regarding catheter -relatives
                                                                                                                              not supportive and ? would cause other
                                                                                                                              problems-to review feeds/water on nights. and
                                                                                                                              conveen now being tried at night only. guidelines
                                                                                                                              reviewed. Ongoing monitoring of condition.
                                                                                                                              27/12/06-discussed with Primary nurse-all currant
                                                                                                                              guidelines relevant and adhered to. On going
                                                                                                                              assessment of situation.

  948 JAC     HIU      OLDCLQ MINOR        Abuse    18/11/06 I went to give a patient his     Patient told that his remarks   discussed with Q/N regards comments made.
                                           etc of            medication at 22.30hrs to find   were not acceptable. He         Q/N had no issues concerning them and had a
                                           Staff by          he was very aggiatated towards   asked to be taken to the        clear understanding of the patients condition.
                                           patients          a fellow colleague. He was       toilet and I escorted him to    appropriate management of the situation and in
                                                             being very racist towards her.   the bathroom.                   accordance to the guidelines. Changing staff over
                                                                                              Whilst the patient was in the   is a good practice to assist in diffusing the
                                                                                              tolet I asked my colleague      aggiation. no further incidents reported to
                                                                                              whether she'd prefer to work    date(29/11/06)
                                                                                              on Cambridge ward & I took
                                                                                              over from looking after him.

  979 JAC     HIU      HIUGEN MINOR        Impleme 06/12/06 In morning hand over night staff Repositioned onto back and       Ward sister raised it at handover. Reported to
                                           ntation          stated they had repostioned       given a wash. This settled      ONC. Night sister on duty so meeting held with
                                           of care          patient on her right side half an her                             Q/N and Night sister. Issues around the incident
                                           or               hour before. She requires the                                     discussed and standards clearly stated especially
                                           ongoing          Symmetrikit sleep system for                                      on careplan reading. Night Sister to mointor Q/N
                                           monitori         safe and comfortable positioning                                  over the next few weeks.
                                           ng -             as she is unable to move
                                           other            herself. She was crying (her
Printed on 23 January 2007 by Anne Fahey                                                                                                                      Page 3
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                            Action taken                     Action taken (Investigation)

                                                               only means of communication)
                                                               during handover. Early staff
                                                               went to her after handover and
                                                               found her lying curled on her
                                                               right side with her arm
                                                               underneath her - still distressed.
                                                               The sleep system was not in
                                                               place. She was also lying on
                                                               her catheter, which had made a
                                                               superficial mark on her hip

  980 SR      HIU      HDU       MINOR     Slips,    08/12/06 Patient on rising from chair          Kept patient seated for a        Discussed in rehabilition meeting by all
                                           trips,             stumbled and fell to the floor.       while to reorientate himself.    disciplines. Investigated to elimate cardiac
                                           falls and          With guidance, positioning chair,     Pro Forma falls procedure        involvement. Generally unsteady;physio
                                           collision          patient was able to pick himself      followed. Doctor not called      concentrating on improving balance and gait, and
                                           s                  up.                                   in this instance but advised     staff advised to give verbal prompting if not
                                                                                                    staff to follow up with doctor   tolerating physical contact. Observations to be
                                                                                                    as the patient has fallen on a   recorded following any further incidents, and
                                                                                                    number of ocassions. Staff       report to medics if concerns regarding cardiac
                                                                                                    N/A with him at the time feels
                                                                                                    he appears to be at risk
                                                                                                    when tired as in this case
                                                                                                    late evening

  978 JAC     HIU      HIUGEN MINOR        Impleme 06/12/06 Patient had been given         Was to have breakfast feed                Clear statement about careplan reading. To
                                           ntation          overnight feed via PEG through given bolus via PEG. This                 observe Q/n performance.
                                           of care          pump. This was stopped the     was not given
                                           or               day before.
                                           ongoing
                                           monitori
                                           ng -
                                           other

  971 JAC     HIU      HDU       MINOR     Slips,    02/12/06 Patient attempted to stand up      Assisted the patient to his         No apparent injury and none noted since injury. 2
                                           trips,             from a seated position and fell feet and returned him to his           other incidents within first 24hours therapeutic
                                           falls and          to the floor landing on his knees. chair.                              interventions in place.
                                           collision          When asked if he was feeling all
                                           s                  right patient replied "yes". When
                                                              asked if he was in pain he
                                                              replied "no".


Printed on 23 January 2007 by Anne Fahey                                                                                                                             Page 4
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                           Action taken                  Action taken (Investigation)

  972 JAC     HIU      HDU       MINOR     Slips,    03/12/06 Patient miss-judged the position Patient was assisted to his       No injury noted and none reported since. 2
                                           trips,             of the chair whilst preceding to feet and then guided into the     previous incidents over the last 24hours. staff
                                           falls and          sit down and landed on his       chair.                            observering and orientating the patient and with
                                           collision          bottom. absolutely no injury was                                   therapy problems being addressed.
                                           s                  sustained and the patient
                                                              confirmed this by saving he was
                                                              "ok".

  964 JAC     HIU      HIUGEN MINOR        Monitori 23/11/06 Patients medication found in          Reported to the nurse in      Ward sister spoke to Q/n concerned. discussed
                                           ng or             shoes.                                charge.                       the importance of staying with patients when
                                           follow up         Two Tablets small round and                                         taking their medication and hospital policy.
                                           of                had a pink colour to them.                                          Careplan checked.
                                           medicin
                                           e use             The Tablets had been partially
                                                             sucked.

  947 JAC     HIU      CLIVE     MINOR     Abuse    17/11/06    Flying kick towards me              from the shoulder level   Indepth decision with the Q/N-debreifing but was
                                           etc of                                                  dashed towards the head of requested to go in more depth about some of the
                                           Staff by                                                the bed for safety         issues. To continue with this with the Q/N.
                                           patients                                                                           guidelines checked-were followed in the incident
                                                                                                                              and Q/N had a good understanding of the
                                                                                                                              principles behind them. Continue to monitore.

 1003 PJD     HIU      SECOND MINOR        Accident 17/12/06 I put the lock of the top left side   nurse went to check the       2nd part of door for all 4 side rooms taped to
                                           caused            of the door. Then the right side      patient and found the door    prevent doors accidentally locking. Facilities
                                           by some           of the door closed the door           locked she immediately        Manager has instructed contractors to remove
                                           other             automatically because the blue        reported to the MLN went      locks from the doors. Still awaiting repairs to be
                                           means             strap on the right side did not       downstairs and got the key    done.
                                                             stick properly to the lock. The       from the reception and
                                                             doors got locked and the patient      opened the doors
                                                             was locked inside.

 1002 DPW     HIU      SECOND MINOR        Slips,    16/12/06 saw patient going down onto          checked vital obs ,within     Observations done 3 times daily due to ongoing
                                           trips,             floor leaning against the bed        normal limits.no injuries     medical problem. All satiasfactory. Patient
                                           falls and          ,reaching for his shoes which        noted ,neither was he         supervised when walking prior to this incident.
                                           collision          were next to his bed on the floor    complaining of any pain.      No longer needed while round ward area.
                                           s                  .Went into room checked for          mentioned it to the doctor    Continue to observe patient. Careplan checked.
                                                              bruises and injuries. Assisted       when he visited the doctor.
                                                              back on to bed with the help of
                                                              two . Also complaining feeling
                                                              weak. Presently has bruises all

Printed on 23 January 2007 by Anne Fahey                                                                                                                           Page 5
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                           Action taken                    Action taken (Investigation)

                                                               over his arms and legs

  997 SS      HIU      CAMBRI MINOR        Slips,    20/12/06 PATIENT IN SHOWER STOOD              HELP CALLED FOR.
                                           trips,             TO ALLOW BOTTOM TO BE                PATIENT ASSISTED TO
                                           falls and          WASHED WENT TO SIT FELL              STAND WITH TWO
                                           collision          TO LEFT SIDE MISSING                 MEMBERS OF STAFF.
                                           s                  CHAIR AND FALLING ON TO              PATIENT SAT ON
                                                              BOTTOM.                              SHOWER CHAIR CHOSE
                                                                                                   TO CONTINUE WITH
                                                                                                   SHOWER.
                                                                                                   DRESSING APPLIED AND
                                                                                                   PROCEDURE FOLLOWED
                                                                                                   FOR LOW FALL NOT
                                                                                                   NECESSARY TO CALL
                                                                                                   DOCTOR

  989 JAC     HIU      GROUN MINOR         Slips,    27/12/06 Patient had just got out of a taxi   Patient was helped up and       Escort provided for further appointments.
                       D                   trips,             on returning from an outpatients     taken to a seat in reception.   Assessment decision discussed with ONC by
                                           falls and          appointment in Bristol. He was       A ward nurse came to collect    ward sister. standard stated that all patients to
                                           collision          outside by the main hospital         him and accompany him           have nurse escort to other depatments.
                                           s                  entrance. No escort. He reports      back to ward in the lift.
                                                              that his knee gave way and he        Observations satisfactory.
                                                              fell. He did not feel dizzy prior    Reported to doctor. No
                                                              this. This was only observed by
                                                              to                                   apparent injury.
                                                              the taxi driver.

  990 DPW     HIU      SECOND MINOR        Administ 26/12/06 staff nurse was about to give   staff nurse was informed as Drug incident form completed. Dr aware of
                                           ration or         injection when patient said he  well as the SHO, green form omission. Nil ordered.
                                           supply            was feeling sick as a result    was filled.                 Discussion with Q/N regarding the incident.
                                           of a              injection was suspended and
                                           medicin           staff nurse forgot to come back
                                           e from a          and give the injection.
                                           clinical
                                           area

  965 JAC     HIU      HIUGEN MINOR        Other    24/11/06 the patient was asleep and        stepped backwards quickly           appropriate care taken at the time of the incident.
                                                             snoring and his breathing sound                                       patient had been positioned correctly previously.
                                                             suddenly was noisy.went to see                                        Care plann updated. Reported to the other
                                                             the patient and find out that he                                      nursing staff in the morning handover
                                                             had shifted position from back to
                                                             left side lying and his left fist

Printed on 23 January 2007 by Anne Fahey                                                                                                                              Page 6
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                          Action taken                     Action taken (Investigation)

                                                              underneath his chin on the
                                                              neck,legs on the floor mattress.I
                                                              carefully moved his hand away
                                                              from his neck, followed by legs
                                                              off from the mattress to bed

  981 SR       HIU       CAMBRI MINOR      Slips,    10/12/06 The patient had walked to the       The patient was assisted to      Discussed in rehabilition meeting by all
                                           trips,             dining table for dinner. He         stand by two staff members       disciplines. Investigated to elimate cardiac
                                           falls and          missed the chair and fell onto      and sat down in the chair.       involvement. Generally unsteady;physio
                                           collision          his bottom to the floor.            The patient was a little         concentrating on improving balance and gait, and
                                           s                                                      shaken but felt alright to eat   staff advised to give verbal prompting if not
                                                                                                  his dinner.                      tolerating physical contact. Observations to be
                                                                                                                                   recorded following any further incidents, and
                                                                                                                                   report to medics if concerns regarding cardiac

  970 JAC      HIU       HDU       MINOR   Slips,    01/12/06 patient found on the floor, sitting ASSESSED                         No obvious injuries and none reported since
                                           trips,             on his buttocks, fully conscious ,OBSERVATION DONE ,OK               then. staff in close observation within HDU.
                                           falls and                                              .                                Physio assessment on admission. 2 other
                                           collision                                                                               incidents with 24hours theraupitic intervention to
                                           s                                                                                       address these problems.

  988 DPW      HIU       SECOND MINOR      Slips,    28/12/06 patient fell down/ lost his         with side support for patient    All care given as per care plan. Staff aware of
                                           trips,             balance while doing a shower        to hold onto, helped patient     balance problems.
                                           falls and          chair to wheel chair transfer       from behind stand up and         No injuries to the patient. careplan checked.
                                           collision                                              get into wheel chair             Ongoing physio therapy.
                                           s

Number of records for Head Injury Unit                                               20




Printed on 23 January 2007 by Anne Fahey                                                                                                                             Page 7
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                     Action taken                   Action taken (Investigation)


Directorate: Operations

  982 DOP      OPERA SWITCH MODER Abuse - 08/12/06 Member of public came in for a            Paged head porter and          Switchboard staff to activate police panic
               T                  other            sit down in the reception area.           David Phillips for assistance. response on any aggressive person who does
                                                   When asked to leave by a porter           David escorted him from the not respond to attempts to help / assist.
                                                   he made threatening remarks to            premises.
                                                   myself and the porter. I felt                                            Take matter again to capital group as a priority
                                                   threatened and frightened and                                            measure
                                                   trapped behind the reception
                                                   desk. The man then started to
                                                   fall asleep in the chair.

  959 DOP      OPERA CATERI        MINOR   Accident 20/11/06 This Member of staff struck     Advised to run under cold
               T                           caused            there hand against the gas      water to reduce bruising
                                           by some           steamer while walking by.
                                           other                                             Awareness training
                                           means                                             instigated by CM


  974 NE       OPERA CATERI        MINOR   Other    19/11/06 This member of staff burn their They ran their hand under      Catering manager to provide training and instruct
               T                                             hand while removing some food water for a couple on            in the use of PPE
                                                             items form the Microwave.       minutes.
                                                                                                                            Catering manager spoke with staff member and
                                                                                                                            told her not to heat baked beans in the
                                                                                                                            microwave. Also to ensure she uses an oven
                                                                                                                            cloth at all times, when handling hot food items.

Number of records for Operations                                                   3




Printed on 23 January 2007 by Anne Fahey                                                                                                                     Page 8
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail     Incident Description                          Action taken                      Action taken (Investigation)


Directorate: Rheumatology

 1000 KB      RHEUM RHPHYS MODER Accident 14/12/06 Patient came out of shower area                Pressure applied directly to
                                 caused            and reported that blood was                    area. Poolside attendant
                                 by some           coming into her shower under                   instructed to pull emergency
                                 other             the partition. Got out of the pool             cord and get medical help via
                                 means             to check. Found patient in                     2222 phone system.
                                                   shower cubicle, bleeding heavily               Pressure maintained until
                                                   from her right lower leg. Patient              medics arrived and took
                                                   unaware that she was bleeding,                 over.
                                                   therefore unable to say how it
                                                   happened.                                      CW emailed requesting
                                                                                                  further detail 18/01/07

  961 CSH     RHEUM VIOLET       MODER Slips,    19/11/06 Patient found collapsed in the          Pull the emergency                Patient found collapsed in the toilet and
                                       trips,             toilet in a semi conscious stage.       bell.Checked the vital            repeatedly lapsed in and out of consiousness for
                                       falls and                                                  observation and informed the      10 minutes.
                                       collision                                                  docter.Placed in the recovery     Staff on duty followed all correct procedures for
                                       s                                                          position.Informed the             out of hours and in event of no doctor on
                                                                                                  ambulance people.Transferd        premises dialed 999 to send patient to RUH for
                                                                                                  to RUH for further treatment      assessment. Doctor contacted and saw patient
                                                                                                  as per the oncall docter.         before transfer.
                                                                                                                                    Patient was retained at the RUH for two days and
                                                                                                                                    had CT head and other routine investigations.
                                                                                                                                    Patient returned to the RNHRD on the 21st
                                                                                                                                    November 06 with 24 hour tape in place. Patient
                                                                                                                                    is now being monitored by medical staff

  975 KB      RHEUM RHPHYS MINOR           Accident 27/11/06 Standing behind the patient we       No injury or harm to patient.
                                           caused            practiced stairs in the physio       Staff member - No
                                           by some           deapartment using small OT           immediate action taken, as
                                           other             block (half the original height of   not aware of injury until early
                                           means             step) at bottom of stairs, patient   evening. Suffered a
                                                             stepped up onto block and 1st        sprained muscle in the back.
                                                             step with no problem.
                                                             When patient had put right foot      CW emailed requesting
                                                             onto 2nd step, the patients left     further detail 18/01/07
                                                             leg lost balance and patient
                                                             started to fall, I put my forearms
                                                             underneath the patients arms to
                                                             support her and stop her from
Printed on 23 January 2007 by Anne Fahey                                                                                                                            Page 9
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail      Incident Description                           Action taken                      Action taken (Investigation)

                                                               falling down onto step. A
                                                               physiotherapist immediately
                                                               helped take some of the
                                                               patients weight and place
                                                               patient into wheelchair.

  987 CSH     RHEUM FIRST        MINOR     Slips,    02/12/06 The female patient was moving         On questioning, she stated        Patient was walking to the toilet using her walking
                                           trips,             towards the toilet, when her          that she had not hit her head     frame and stooped to pick up her nightdress
                                           falls and          nightdress, which was hanging         and had no pain. Having           which had fallen to the ground. The patient
                                           collision          over the front of her Zimmer          rested for a few minutes, she     overbalanced and slipped to the floor. On
                                           s                  frame fell to the floor. Whilst       was assisted to her feet.         assessment by nursing staff she was unhurt and
                                                              attempting to retrieve the article,   She then continued on her         was able to stand with assistance from staff. No
                                                              she slipped to the floor. She         way to the toilet, under          further investigation required.
                                                              was found some minutes later          supervision of a staff
                                                              seated on the floor, leaning          member.
                                                              against the wall. She appeared
                                                              unhurt.

  977 KB      RHEUM RHPHYS MINOR           Accident 30/11/06 Patient dropped a chair onto           Checked by Physiotherapist
                                           caused            another patients toe.                  in charge. Toe red, some
                                           by some                                                  blood around nail. No
                                           other                                                    treatment required.
                                           means

  976 KB      RHEUM RHPHYS MINOR           Accident 27/11/06 Noticed PTA with patient in            Patient unharmed.
                                           caused            physio dept on steps, patient          No immediate action taken.
                                           by some           lost power in legs gave way, ran       Staff member - Felt a pull in
                                           other             over to give assistance to             the right shoulder at the time,
                                           means             support patients weight to             no immediate symptoms until
                                                             prevent a fall and to assist PTA       early afternoon, took
                                                             in guiding patient into                paracetamol in the evening.
                                                             wheelchair.
                                                                                                    CW emailed for extra detail
                                                                                                    on staff member - 23/1/07

  985 KB      RHEUM RHPHYS MINOR           Other     04/12/06 Hydrotherapy pool water sample        Rheum Lead informed.
                                                              of 30/11/2006 not received in         Facilities Manager informed.
                                                              lab until 12.30 4/12/2006.            Lab are also looking into it.
                                                              Sample of 4/12/2006 not yet           Have spoken to our courier,
                                                              received. Samples should be           who states that samples are
                                                              received in the lab within 6          always collected at 10am.

Printed on 23 January 2007 by Anne Fahey                                                                                                                              Page 10
17/11/06 - 22/01/07
 Datix Handle Director Location Severity Detail   Incident Description                 Action taken                   Action taken (Investigation)

                                                           hours of being taken.       On checking just after 10am,
                                                                                       samples are always gone.

Number of records for Rheumatology                                                 7




Total number of records              30


Printed on 23 January 2007 by Anne Fahey                                                                                                             Page 11
17/11/06 - 22/01/07

				
DOCUMENT INFO