Public Board of Directors papers 241122

1. Safe

1.3 – Moderate+ Incidents

October 2022 Reference

Grade Description

Outcome

Moderate (3) Moderate (3) Moderate (3) Moderate (3)

SACT Reaction - patient collapse and crash call, resus to CCU. Paclitaxel reaction MDT Surveillance queried further treatment in October 2022 but patient had been omitted from earlier MDT depsite referral.

W73151

Identified as known complication

W73155

Undergoing RCA

W73164

Omitted medication

Undergoing RCA

W72234

Lost to follow up

Undergoing RCA

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