Public Board of Directors papers 260123

1. Safe

1.3 – Moderate+ Incidents

December 2022 Reference

Grade

Description

Outcome

W74351

Major

AKI and drug contraindications- related to sepsis RCA

Undergoing SI process

Undergoing investigation

W73914

Moderate

TIVAD complications- line migrated into cavity

Staff member slipped on water in side room (Ward 10) and hurt right knee

Undergoing RCA

W74016

Moderate

Undergoing investigation

W74221

Moderate

Internal referral made on 22/8/22 and not actioned.

Undergoing RCA

W73523

Moderate

Upgraded- denosumab given but low Ca levels

Undergoing RCA

W74471

Moderate

Omitted antibiotics

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