Page 85 - KPJ_2011

Table 3:
Incidents Being Monitored
1 Patient Fall
2 Medication Related
• Prescribing
• Dispensing / preparation (Pharmacy)
• Administration (Nursing)
3 Sentinel Events
• Retained instruments / swabs
• Severe hemolytic blood transfusion reaction due
to ABO incompatibility
• Baby identification error
• Intravascular gas embolism leading to death or
severe injury
• Maternal death / severe morbidity
• Medication error leading to death or serious
adverse event
• Suicide/ para-suicide/self-harm
• Unexpected death
• Wrong patient / wrong site / wrong procedure /
wrong body part
• Fall with serious injury / death
4 Blood Transfusion Related
• Laboratory error
• Wrong patient / wrong blood
• Blood transfusion reaction - haemolytic (mild)
• Blood transfusion reaction - others
5 Sharps Injury
• Needle Stick Injury (Patient, Staff & Student)
• Other Sharps Injury (exclude needle stick)
6 OSH Related
• Injury to staff (at work, coming & going home
from work)
• Injury or incident related to patient, visitor or
outsourced staff/contractor
• Electric events (affecting patient / staff safety)
• Cytotoxic spillage
7 Discharge Related (Clinical)
• Dis-satisfaction with service
• Service not available
• Discharge Against Medical Advise
• Poor prognosis
• 2nd opinion Nursing Services Related
8 Nursing Services Related
• Communication related incidents affecting clinical
care
• Delay in carrying out orders
• Nursing process error / failure
• Error in documentation / documentation related
• Bedsore (severe) Grade 4 muscle & bone exposed
• Thrombophlebitis
9 O&G Services
• Maternal events (maternal deaths reported under
sentinel events)
• Delivery events / injury to baby during delivery
• Perinatal deaths
10 ICU Services
• Readmission to ICU within 24 hours
• Unplanned transfers to ICU / HDU
• Adverse clinical events - Dislodged ETT /
monitoring lines
11 OT & CSSD Services
• Cancellations (not related to biomedical equipment)
• Incomplete consent forms
• Operative delay (not related to biomedical
equipment)
• OT - Infection control related
• Pre-operative assessment not done
• Medical records related (missing test results, x-ray, etc)
• Unplanned return to OT
• CSSD - infection control related
12 Hospital Wide General Events
• Allergic reaction – medication or non-medication
related
• Burns / Scalds
• Clinical procedures (adverse outcome / error /
failure) - doctor related
• Complication (unpredicted) NOT during or related
to surgery or procedure
• Complication (unpredicted) occurring
during or within 24 hours of all operative &
interventional procedure
• Delayed care - bed or equipment not available
• Medical supply (causing delay in clinical care) -
not available / insufficient stock
13 Equipment / Device Related
• Biomedical equipment failure affecting clinical care
(exclude lost/missing)
• All other medical equipment failure affecting
clinical care (exclude lost/missing)
14 Customer Feedback (Anecdotal)
• Dissatisfied with Doctor, nursing service
or support service
• Dissatisfaction with service / facility
15 Medical Records Related
• Records misplaced / lost
• Incomplete (no admission form, discharge
summary, etc)
• Information security breach
16 Laboratory Services
• Hematoma at bleeding site
• Missing specimen / result
• Service interruption
• Wrong patient / wrong procedure / wrong result
17 Diagnostic Imaging Services
• Exposure to pregnant women
• DID - Wrong person / wrong site / wrong procedure
• Delay in carrying out orders
• Service interruption
18 Radiotherapy Services
• Radiotherapy - Wrong person / wrong site / wrong
procedure / wrong dose
• Delay in carrying out orders
• Service interruption
19 Food Services
• Food safety / hygiene
• Wrong person / wrong diet
20 Discharge Related (Non-Clinical) Incidents
• Financial constraints / no insurance cover
• Absconded
• Appointment at other Hospitals
• Bed Constraint
ANNUAL REPORT 2011 80