Public Board papers 31.03.22

1. Safe

1.3 – Moderate+ Incidents

February 2022 Reference

Grade

Description

Outcome

Clinical impact; patient sustained a fractured neck of femur. Progressing to full patient safety investigation.

W67582

Major

Outpatient fall in glass corridor.

A patient had a portacath inserted by The Christie early November 21. A few weeks later admitted to his local trust with a high temperature, the portacath was found to be infected.

Clinical impact; the patient sadly died as a result of the infection found in the portacath. Progressing to full patient safety investigation

W67756

Death

No ongoing clinical impact. Progressing to full patient safety investigation to identify learning. Clinical impact; patient required return to theatre. Review of unintended event via surgical mortality and morbidity process.

W67781

Moderate Intravenous medication delivered to a patient too quickly.

W68059

Moderate Bowel perforation as a recognised consented complication but unintended consequence of surgical procedure.

Clinical impact; patient required admission to oncology critical care unit and sadly died a few days later. For review through M&M process and any learning identified and shared.

W67733

Moderate Recognised consented but unintended reaction to immunotherapy treatment.

Clinical impact: patient sustained a fractured fibula. Accident occurred outside of hospital premises, full investigation not required. Patient able to continue to receive planned treatment.

W67755

Moderate Patient slipped and fell between hospital premises and car park.

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