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Serious Adverse Events 2013/14

Reporting serious adverse events nationally is an important part of improving health outcomes for New Zealanders by improving safety, and encouraging open and transparent reporting of incidents when something goes wrong.

An adverse event is an incident which results in harm to people using health and disability services. Where those adverse events are serious these are reported to the Health Quality & Safety Commission, in line with its national reportable events policy. Serious adverse events are in general those events where serious harm to a consumer or death has occurred.

The Serious Adverse Event report is used to support our continuous quality improvement strategy, focusing on shared learning to improve systems and minimise the possibility of future incidents.

You can review our latest report below and/or see the Health Quality & Safety Commission website for the national report.

 

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

Bay of Plenty District Health Board Summary

1 July 2013 to 30 June 2014

Description of Event

Review Findings Recommendations/
Actions
Follow Up    

Falls Events

Inpatient fall resulting in fractured hip

Unwitnessed fall. Falls risk assessment completed prior to incident and patient able to mobilise independently. No contributing factors identified.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events                                                  

Inpatient fall resulting in fractured hip

Patient did not ring the call bell, was reaching out to get their walker, missed and hit the floor.

Falls risk assessment completed prior to fall - patient able to transfer and mobilise with frame and supervision. Intentional rounding occurred 15 minutes prior to incident and walker was within reach.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Inpatient fall resulting in dislocated hip requiring surgery

Patient transferred from Orthopaedic Ward following surgery for a fractured hip to Rehabilitation Ward where they fell shortly after arrival, dislocating hip requiring further surgery.

Prior to incident, patient was able to mobilise using walking frame and with supervision.

Call bell was within reach. Patient reported an urgent desire to use the bathroom and mobilised without assistance. In the bathroom their legs felt weak, gave way and they fell to the ground.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Inpatient fall resulting in fractured shoulder

Patient reports they were walking in their room, felt dizzy, grabbed hold of the foot of the bed and collapsed.

Assessments and care plans completed prior to the incident.

Strategies had been implemented to reduce risk and maintain independence. Patient had a medical condition which increased falls risk.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Inpatient fall resulting in fractured pelvis.

Unwitnessed fall. Patient reported they lost their balance in the bathroom.

Patient had multiple medical conditions which increased falls risk. Prior to the incident a falls risk assessment and care plan were completed.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Inpatient fall resulting in subdural haemorrhage/brain bleed.

Unwitnessed fall. Patient states they were getting up to go to the toilet and slipped. Falls risk assessment was completed and risks and management identified prior to the incident but not documented in care plan.

Patient assessed as requiring assistance when mobilising and able to request assistance. On this occasion did not call for assistance.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Inpatient fall resulting in acute/chronic subdural haematoma/brain bleed

Assessed as falls risk prior to incident and care plan was in place. Patient's physical health started to deteriorate and three hours before the fall was noted to be confused and disorientated, falls care plan unchanged. Had been seen during rounding 15 minutes prior.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Inpatient fall resulting in fractured hip

Patient attempting to go to toilet moved from edge of bed but stopped by intravenous tubing in arm, causing the patient to spin around and fall.

Inadequate/no falls risk assessment, no falls care plan and inappropriate footwear.

Reviewed

See note beneath table: Actions Being Taken In Response to Falls Events

Non-Falls Events

Death as a result of sepsis secondary to peritonitis.

Delay in recognising a small bowel perforation. This resulted in the patient, who had a palliative condition, not receiving optimum care.

Areas of concern identified, that contributed to the delay, include communication, reliance on bladder ultrasound and a failure to fully consider other possibilities for the patient's condition.

Formal, structured multi-disciplinary handovers be implemented at 10pm.

Changes to how Amiodarone is prescribed.

Critical note to be added to the Lippincott procedure, alerting staff to consider other reasons for nil urine output and the potential for false readings with a bladder scanner.

All actions completed

 

Actions Being Taken In Response to Falls Events

The BOPDHB has an established falls prevention programme which is continually monitored and reviewed to ensure best practice is applied to reduce harm from falls.

Currently there are two falls working groups in operation. One reviews the organisational Reportable Event Forms (REFs) related to a fall and the second monitors what is happening nationally, regionally and locally.

Some examples of outcomes from these groups are:

  • changes to floor mopping processes and associated education
  • ongoing education emphasises the need for reassessment of falls risk care plan when patient mental status changes
  • ward unit level work has adopted a bottom up approach giving individual wards ownership of the programme
  • intentional rounding includes environmental check, including that aids are within reach
  • non-slip socks standardised to socks with grips all around the foot and better fitting.

The falls prevention programme has an emphasis on documented falls risk assessment and care plan. Compliance with falls risk assessment and care plan monitored through the quality and safety markers (QSM).

Improving documentation will remain a focus area in this coming year.

 

Quality Account 2014

Click here to read the BoPDHB Quality Account 2014

 

Serious Adverse Events 2012-2013

Click here to see the Serious Adverse Events Report from July 2013 to June 2013.  

 

Last updated: August 29, 2018