Problem Statement

Any injury suffered by a patient during their stay in hospital is truly regrettable. CM Health is committed to learning from incidents of serious harm so that similar incidents do not happen again.

What are we trying to achieve?

Each year, in association with the Health Quality and Safety Commission, CM Health releases a summary of the in-depth and comprehensive investigations that have taken place after every serious incident.

The report for 2018/2019 will be released in late 2019.

What have we done?

Injuries suffered by patients when they fall are the most common ones in the hospital. Falls cause more minor, moderate and severe injuries than any other type of reported incident.

 In this year’s report, 23 patients were seriously injured after a fall. These injuries included significant head injuries or broken bones. Each of the incidents was reviewed to ensure that CM Health’s comprehensive falls prevention programme had been followed.

Understanding where improvements are needed to the falls prevention programme and how to better help staff keep patients safe are the main drivers for the review.

Over the past year, there has also been ongoing work to ensure accurate and timely assessment of falls risk and reliable implementation of falls prevention interventions.

In addition to falls, there were 12 other incidents leading to actual or potential serious patient injury.

In the past 3 years, there has been a drive to report all moderate-to-severe hospital acquired pressure injuries. In this year’s report, we have investigated the causes of two pressure injuries. There has also been increased attention to incidents relating to birthing and three cases have been reviewed in depth. There were five cases where delays in treatment led to progression of disease that may have be preventable. The causes for the delays have been reviewed and actions taken where practical to prevent these delays.

In the past year, there has also been increased focus on always reporting and reviewing events. These are events where, although no or little harm came to the patient, lessons can be learnt to prevent their recurrence. There were 10 cases in the Radiology Department where the wrong patient received an X-ray or a wrong body part was X-rayed. The investigations highlighted problems with ordering tasks and correctly identifying patients. There were also three cases where swabs were left in place for longer than planned.

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