1. Incident Id | 513561-20 |
2. Incident date | 15/07/08 |
3. Specific service | Emergency medicine; aged care—geriatrics
|
4. Time band | 11:00 to 11:59 |
5. Incident type(s) | Clinical management |
6. Principle incident | Clinical management |
7. Incident description | Documented in patient's notes that the patient was not to be moved to a ward before a CT, and surgical review had been attended. Neither had been attended when the patient arrived on ward. It was also not handed over that the patient was known to have MRSA, before the patient had been placed into a full four-bedded room. |
8. If the problem was associated with transfer of care, it was about: | Inadequate handover |
9. What was the outcome for the subject? | – |
10. Actual severity assessment code | 4 |
11. Initial action taken | Infection Control notified, patient reswabbed, other patients in room now also to be swabbed including wounds; patient moved to single room once available after relocating several patients. |
12. How could the incident have been prevented? | Better handover prior to transfer, Emergency nursing manager following medical advice and requests |
13. Results of incident | – |
14. If the incident has an outcome, what was it? | – |