Board of Directors papers 271022

1. Safe

1.3 – Moderate+ Incidents

September 2022 Reference

Grade Description

Outcome

W71867

Moderate Delay in booking surgery

Themed review of urology pathway in progress

Known side effect of treatment. Admitted overnight and discharged home the following day.

W71884

Moderate SACT reaction

W71945

Moderate Delay in booking surgery

Themed review of urology pathway in progress

Successfully resuscitated and transferred to Critical Care Unit. Now discharged from Hospital

W72035

Moderate Cardiac arrest during surgery

W72175

Moderate Medical gauze found within sinus cavity, during surgery

Initial investigation revealed that it was not surgical gauze – likely packing gauze.

Removed in surgical theatre without incident. Investigation to identify root cause underway. Known side effect of treatment. Admitted overnight and discharged home the following day.

W72200

Moderate Fractured epidural catheter

W72382

Moderate SACT reaction

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