Public Board of Directors papers 30 June 2022

1. Safe

1.3 – Moderate+ Incidents

May 2022 Reference

Grade

Description

Outcome

W69762

Moderate A known complication of nephrostomy exchange where a patient required admission for IV antibiotics

Formal complaint response to family. Review via interventional radiology M+M.

Clinical impact, patient requires repeat procedure. Progressing to full patient safety investigation. Clinical impact, patient required admission to CCU, however has made full recovery. Review by SACT delivery group.

W69794

Moderate Cytology samples were not received following a day case invasive procedure.

W69446

Moderate A patient suffered a cardiac arrest following administration of chemotherapy.

W69740

Moderate A positive microbiology result was not reviewed. The patient subsequently required admission for IV antibiotics

Clinical impact, patient required admission. Progressing to full patient safety investigation.

W69551

Moderate Deviation from process for monitoring of CMV status in a transplant patient

Clinical impact unknown at present. Progressing to full patient safety investigation.

Clinical impact, patient progressing to surgery. Progressing to full patient safety investigation

W69717

Moderate There was a missed opportunity to refer spinal fractures identified on imaging to a surgical team in a timely manner

W69897

Moderate A referral was not processed correctly, resulting in a patient being lost to follow up for 9 months.

Clinical impact, progression of lesion. Progressing to full patient safety investigation

Clinical impact unknown at present. Progressing to full patient safety investigation. Reportable under IR(ME)R

W69938

Moderate Incorrect plan used for 4/5 fractions of radiotherapy resulting in irradiation of anatomy outside of treatment field

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