Your DHB

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

Bay of Plenty District Health Board Summary

1 July 2012 to 30 June 2013

Description of Event

Review Findings

Recommendations/Actions

Follow Up

Inpatient fall resulting in fractured hip.

Unpreventable fall.

Patient with a history of dementia attempted to go to the toilet without assistance.

Identified as high falls risk, but able to mobilise using a walking frame with supervision. 

Nil

Nil

Inpatient fall resulting in fractured hip.

Unpreventable fall.

Patient fell on the way to the toilet. Handover included information regarding mobilisation and this was in place at time of fall.

Nil

Nil

Inpatient fall resulting in fractured hip.

Unpreventable fall.

Patient assessed as falls risk, care plan in place.  Was being closely monitored at time of fall but pushed nurse out of the way before falling to knees.

Nil

Nil

Inpatient fall resulting in fractured hip.

Appears to be unpreventable fall.

Patient had been assessed as high falls risk. Had been observed sleeping approximately an hour before this incident.

Patient had been given sleeping tablets but awoke during the night and, disorientated, got up to go to the toilet.

Nil specific to this incident. Falls programme in place.

Nil

Inpatient fall resulting in fractured hip.

Elderly patient with confusion got out of bed quickly.

Bed had two mattresses (ordinary and air) made it higher than usual.

Patient was not assessed as being a high falls risk.

BOPDHB has a - SAFE MOBILISATION - reducing harm from inpatient falls programme. Results of this programme to date have been promising and further improvement and sustainability is now the target.

Interventions implemented at BOPDHB are:

  • Intentional Rounding - promotes an awareness of patient's condition, that their environment is safe, their needs are met, and they have regular access to staff.
  • A focus on prevention, detection and treatment of delirium.
  • An individualised multi-disciplinary plan of care (rather than solely nursing).
  • Review and, where appropriate, discontinuation of 'culprit' medications associated with increased risk of falls.
  • Continence management, including routines of offering frequent assistance to use the toilet.
  • Early access to advice, mobility aids and, where appropriate, exercise from physiotherapists.
  • Assessment for safe footwear.
  • Staff and patient education.

 

 

Inpatient fall resulting in fractured hip.

Unwitnessed fall.

Patient identified as falls risk.

Patient had call bell but decided to mobilise, using a frame, independently with bare feet and slipped.  

Inpatient fall resulting in fractured hip.

Patient with dementia and lack of ability to call nursing staff for assistance.

Assessment and care plan up to date however patient was not wearing non slip socks. 

 

Inpatient fall resulting in fractured hip.

Patient had a fall within two hours of transfer to another ward.

Verbal (phone) handover does not appear to have covered the patient's needs in relation to falls risk.

Inpatient fall resulting in fractured pelvis.

Requirements for assessment and documentation of falls risk on admission not met.

Inpatient fall resulting in fractured neck

Patient whose mobility, using a stick, was assessed as good. On this occasion did not ring bell for assistance and did not use walking stick.

Non-slip socks had not been provided on this occasion.

Inpatient fall resulting in dislocated hip resulted in increased length of stay

Event occurred within two hours of being transferred from another ward and just prior to a meal time.

Patient with dementia and staff had not had time to complete assessment and care plan in new environment.

Delayed diagnosis of breach baby resulting in death

Findings pending

 

 

 

Last updated: August 29, 2018