Your DHB

Bay of Plenty District Health Board Summary

1 July 2016 to 30 June 2017

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

Description of Event

Review Findings

Recommendations/Actions

Follow Up

Harm from Falls: Falls in hospital have a huge impact on the patient and their family/whanau. The work that has been undertaken has shown improvement against the HQSC outcome measure.

 

Inpatient fall resulting in death due to subdural haematoma

Elderly patient who had a falls risk assessment completed and care plan in place. Despite being supervised patient fell while dressing after a shower and struck head causing a subdural haematoma.

 

Patient very unwell on admission. On review the fall, which was an unfortunate accident, was deemed a contributing factor in the patient's death.

NIL

NIL

Inpatient fall resulting in death due to subdural haemorrhage

Elderly patient, who was extremely unwell due to multiple comorbidities, assessed as high falls risk. Falls prevention strategies implemented unclear if invisibeam activated.

 

Unwitnessed fall.

Need to ensure the invisibeam is positioned accurately to pick up patient movement.

Ongoing education regarding placement of invisibeams.

Inpatient fall resulting in fractured hip

Elderly patient with history of involuntary movements and other comorbidities fell when trying to get up.

 

Plan - to assist patient to mobilise, nonslip socks, call bell within reach (not activated by patient for assistance) - was in place. Patient also positioned in room close to nurses' station and rounded/checked 20/30mins prior to fall.

Requirements for assessing and documenting falls risk assessment subject to ongoing education and training.

Ongoing

Inpatient fall resulting in fractured ankle

Elderly patient assessed as a high falls risk due to cognitive impairment and general weakness. Required assistance with mobilising, attempted to mobilise without assistance and fell.

 

Unwitnessed fall.

All high risk patients with cognitive impairment to have an ultra-low bed and full head-to-toe assessment following a fall.

Ongoing

Inpatient fall resulting in fractured hip

Elderly patient with multiple comorbidities assessed as high falls risk and plan of care identified which included using a walking frame to mobilise.

 

Patient had been allocated a walking frame but refused to use it.

 

Unwitnessed fall.

NIL

NIL

Inpatient fall resulting in fractured hip

 

Elderly patient assessed as falls risk and an appropriate plan of care implemented. Patient was very unwell and had been fully assessed 20 minutes prior to the incident.

 

Unwitnessed fall.

NIL

NIL

Inpatient fall resulting in fractured hip

 

Elderly patient with complex behaviours was assessed and identified as a high falls risk. Despite a comprehensive plan of care in place the patient had an unwitnessed fall during the night.

NIL

NIL

Surgical Site Infections - SSI (Deep) - Met the criteria for reporting as part of ongoing surveillance of SSI. BOPDHB like other DHBs has not previously reported these events but chose to start reporting as it is a key indicator of patient safety. 

Surgical site infection following hip replacement

 

Patient underwent an elective hip replacement, two months post original surgery diagnosed with deep infection at site resulting in further surgery. Reviewed at service mortality and morbidity meeting; no actions identified which could have prevented this.

NIL

NIL

Surgical site infection following hip replacement

Patient had to return to theatre for washout of hip following total hip replacement two weeks prior.

 

Patient had significant risk factors for infection.

Ongoing auditing of SSI and compliance with quality and safety markers.

Ongoing

Surgical site infection following hip replacement

Patient underwent total hip joint replacement with uncomplicated recovery. Readmitted three weeks post-surgery with infection requiring return to surgery for wash out.

 

Procedure followed best practice. No issues found with theatre environment.

 

Patient was nursed in four-bedded room post-surgery; on day two new admission into the room with hip cellulitis.

Increased emphasis on hand hygiene and vigilance on patient placement in the surgical ward.

 

Ongoing auditing of SSI and compliance with quality and safety markers.

Ongoing

Surgical site infection following hip replacement

Patient readmitted with deep surgical site infection 17 days post total hip joint replacement.

 

Multiple risk factors which contributed to infection. No breach in procedures identified.

Ongoing auditing of SSI and compliance with quality and safety markers.

Ongoing

Clinical events

Unexpected outcome following surgery

Patient admitted with severe sepsis, from a complex abscess in the neck. Surgery was indicated and appropriate. The operation was long and complex requiring extensive neck flexion.

 

This was high risk surgery and even if neck flexion had been kept to a minimum paralysis could still occur as an unexpected complication. Permanent paralysis.

Share the learnings to highlight the need to be aware of the possibility of spinal stenosis in patients undergoing complex neck surgery.

Actioned

Delayed treatment resulting in

heart damage

Patient left the department without staff being aware, returned the next day in a worse condition, resulting in unnecessary harm.

 

Due to a lack of signals in the system when the patient initially presented they were not identified and managed as a GP referral resulting in delays in care.

 

The demand and capability of department was extreme and required a crisis response.

Systems and processes in the department reviewed and updated to mitigate the possibility of a similar event.

 

The learnings from this event informed changes in the department and issues addressed.

Wrong patient received MRI

Patient received MRI intended for another patient.

 

Two referrals for two different patients with the same name and similar age were received by radiology one was for an MRI and the other a CT.

Process reviewed referrals for patients with the same name are not to be processed together. 

Staff reminded of care required when processing referrals for patients with the same name.

Last updated: August 29, 2018