Bay of Plenty District Health Board Summary

1 July 2015 to 30 June 2016

Learning from Adverse Events (excluding mental health events) reported to Health Quality & Safety Commission

Description of Event

Review Findings


Follow Up

Inpatient fall resulting in fractured NOF


Elderly patient with dementia had a restless night, getting up and down, and on this occasion slipped. Patient was assessed as being at risk of falls on admission and was wearing non-slip socks and incontinence products but the risk assessment had not been updated to reflect current needs.

Risk assessments need to be regularly reviewed and updated in line with changes in clinical presentation and treatment plans updated accordingly.


Consider trial of an Invisi beam to see if this would be sturdier and the client is not able to step over this.

Requirements for risk assessment and care planning are ongoing.


Invisi beams were trialled but not deemed appropriate. A bell mat for each bed space in the mental health older person's ward have subsequently been purchased.

Inpatient fall resulting in fractured leg (Femur)


Unwitnessed fall. Falls risk assessment and careplan completed and reflective of current requirements. Patient had a history of dementia and was being supported in hospital by family who stayed overnight. At time of the fall staff were unaware that family had left.

The DHB has a care capacity demand management programme which includes variance response management, this is reviewed regularly and strategies put in place to meet demand.


Inpatient fall resulting in fractured ribs

Patient admitted with fractured hip and was recovering in rehabilitation ward. Was identified as at high risk of falls, falls careplan in place and was wearing appropriate non-slip footwear at the time.



Inpatient fall resulting in fractured leg (Femur)


Elderly patient assessed as at high risk of falls, requiring assistance when mobilising. Was mobilising with walking frame to the bathroom with assistance from a family member and staff. Patient had sudden collapse, fall broken by people assisting.



Inpatient fall resulting in fractured pelvis


Elderly patient went to toilet without calling for assistance and had an unwitnessed fall resulting in fractured pelvis. Patient stated had been to the toilet, turned to shut door and fell.


Assessed as being at high risk of falls, requiring assistance when mobilising and invisi beam in place. Patient went to toilet without calling for assistance, no footwear on and invisi beam found to be off as result of earlier intervention.

Reminders to staff, to be vigilant with patients who have invisi and ensure they are switched on as part of the "rounding" check.


Patients who are at high risk of falls and may suffer cognitive lapses should wear non slip socks in bed as well as having slippers by the bed.


Inpatient fall resulting in fractured knee


Patient had been assessed as at risk of falls and plan was for them to be assisted to the bathroom. On this occasion the call bell was within reach, however the patient decided to attempt mobilising independently with frame. As patient got out of bed and attempted to move with frame they fell, landing on their knees.



Inpatient fall resulting in fractured hip



Patient mobilising from x-ray slide to own bed. Nurse sat patient on the side of the bed and placed the walker in front of them. The nurse was organising the patient's IDC, IV lines, machines and monitors etc. when the patient suddenly fell forwards into the frame which slipped underneath them and they fell on the floor.


Learning outcome: prepare the patient for stages of mobilisation (communicate each step prior). Plan to talk the patient through each step and assess patient ability to physically perform the next step. RN to keep one hand free to steady the patient if required.


Wrong site surgery - incorrect skin lesion removed


The correct leg was marked but not the lesion. This was picked up during a check once the patient was anesthetised. Efforts were made to identify the likely lesion for removal and an agreement reached and surgery proceeded. Subsequently found the wrong lesion removed.



Review Surgical Safety Checklist Protocol and work with the Perioperative Improving Surgical Safety Team to ensure requirements for marking of skin lesions is explicit.


In cases where there is uncertainty the surgery must not proceed.


Mode of surgery not consented to.


Patient booked for a hysterectomy was expecting the procedure to be performed as a total laparoscopic hysterectomy (TLH) but surgery performed as a total abdominal hysterectomy (TAH).


Reasons for this were that there were two different Notices for Admission (NFA) for the same patient, one for TLH and one for TAH.


The consent section of the form for the procedure was mistakenly sighted as having been correctly signed during the pre-operative 'Sign-In' check. 


The omission was noted when the patient was anesthetised prior to surgery but the decision was made to proceed without the proper signed consent.

  1. Pathway by which the DHB receives and processes NFAs is reviewed with special reference to these events.
  2. That Protocol Informed Consent - Standards is reviewed in light of these events.
  3. That full engagement, progress monitoring and support is given to the DHB's participation in the Health Quality & Safety Commission's 'Safe Surgery' programme. 

Completed - no further issues since.

Current foci for this national programme are:

  • The Safe Surgery Checklist
  • The 'Improving Surgical Teamwork and Communication'.
Last updated: November 21, 2019