WHaM MCRM Report September 2015
Clinical INCIDENTS Total = 186
Column Labels
Count of Incident type(s)
2 3 4 (blank) Grand Total
3 95 77
11
186
Themes


22 PPH>1500ml
Clinical Incidents associated with NSQHSS (N=54)
NSQHSS
Standard 5 Pt Identification 7 procedure matching- newborn pathology sample labelled as B/O (mothers
name) was rejected by path.lab attendant as pathology department has baby known to them as the
newborn admitted under her father’s surname.
Standard 7 blood and blood products-Cord blood taken from newborn was not sent to path – found under
newborn’s cot at 24 hours post birth.
Standard 8 Pressure Ulcer-contributory factors - age, renal disease, High BMI, reoccurrence, Newborn ID
band on ankle * 2 occasions
Standard 10 Falls- contributory factors: dehydration *2 occassions, faint in shower post birth, slip
(inappropriate footwear); post birth not fully recovered after an epidural; slip on water
Incident Location
(All)
Clincal incident type assoc. with NSQHSS
Blood/Blood Product
Blood/Blood Product;Documentation
Blood/Blood Product;Obstetric - Maternal
Blood/Blood Product;Obstetric - Maternal;Clinical Management
Clinical Management;Documentation
Documentation
Documentation;Health Care Associated Infection/Infestation
Fall
Health Care Associated Infection/Infestation
Medication/IV fluid
Medication/IV fluid;Clinical Management
Medication/IV fluid;Documentation
Medication/IV fluid;Nutrition
Medication/IV fluid;Obstetric - Foetal
Pressure Ulcer
Grand Total
SAC
2 3 4 Grand Total
1
1
1
1
2 1
3
1
1
5 1
6
2 5
7
1
1
1 5
6
1
1
3 13
16
2
2
1 2
3
1
1
1
1
1 3
4
1 18 35
54
Sac 1(n=0)
Completed RCA from July & August
 Death of 22 day old neonate delayed response to deterioration and subsequent treatment for sepsis
Contributory factors include issues relating to- clinical handover, failure to recognise deteriorating pt, documentation
on SNOC,support of AH junior medical staff, culture to minimise ‘unnecessary” contact with the on call VMO, delay
with initiating treatment
 30yr old woman post 2nd pregnancy DOA 10 days post birth –VTE
Contributory factors include issues relating to- noncompliance with documentation of VTE assessment tool, risk
management plan not developed or implemented
MCRM Report September 2015
Page 1
Sac 2 (n= 3)
Actual SAC 2
SAC
MBH Labour Ward
Blood/Blood Product;
2
1
Obstetric - Maternal;
Clinical Management
Tamworth BH Labour ward
Clinical Management
Tamworth BH Ward 9
Obstetric - Foetal;
Obstetric - Maternal;
Clinical Management
Grand Total
1
1
1
1
1
3
Sac 3 (N=95)
Actual SAC 3
Accident/Occupational Health and Safety
Blood/Blood Product;Obstetric - Maternal
Clinical Management
Clinical Management;Documentation
Clinical Management;Medical Device/Equipment/Property
Clinical Management;Organisation Management/Service;Accident/Occupational Health and Safety
Documentation
Documentation;Health Care Associated Infection/Infestation
Fall
Medical Device/Equipment/Property
Medication/IV fluid
Medication/IV fluid;Clinical Management
Medication/IV fluid;Documentation
Nutrition
Nutrition;Obstetric - Foetal;Obstetric - Maternal;Clinical Management
Obstetric - Foetal;Clinical Management
Obstetric - Foetal;Obstetric - Maternal;Clinical Management
Obstetric - Foetal;Obstetric - Maternal;Clinical Management;Organisation Management/Service
Obstetric - Foetal;Organisation Management/Service
Obstetric - Maternal;Clinical Management
Obstetric - Maternal;Clinical Management;Organisation Management/Service
Obstetric - Maternal;Health Care Associated Infection/Infestation
Obstetric - Maternal;Medical Device/Equipment/Property
Pressure Ulcer
Grand Total
MCRM Report September 2015
SAC
3
1
2
19
5
2
1
2
1
1
2
3
2
1
1
1
8
4
2
2
31
1
1
1
1
95
Page 2
Sac 4 ( N=77)
Actual SAC 4
SAC
Accident/Occupational Health and Safety
Aggression - Aggressor
Behaviour/human performance
Blood/Blood Product
Blood/Blood Product;Documentation
Blood/Blood Product;Obstetric - Maternal
Clinical Management
Clinical Management;Accident/Occupational Health and Safety
Clinical Management;Behaviour/human performance
Clinical Management;Complaint
Clinical Management;Documentation
Clinical Management;Pathology/Laboratory
Documentation
Fall
Health Care Associated Infection/Infestation
Medication/IV fluid
Medication/IV fluid;Documentation
Medication/IV fluid;Nutrition
Medication/IV fluid;Obstetric - Foetal
Nutrition
Obstetric - Foetal;Blood/Blood Product;Obstetric - Maternal;Clinical Management
Obstetric - Foetal;Clinical Management
Obstetric - Foetal;Obstetric - Maternal;Clinical Management
Obstetric - Maternal;Behaviour/human performance
Obstetric - Maternal;Clinical Management
Obstetric - Maternal;Clinical Management;Organisation Management/Service
Obstetric - Maternal;Fall
Organisation Management/Service
Pressure Ulcer
Grand Total
4
1
1
2
1
1
1
14
1
1
1
1
1
5
5
1
13
2
1
1
1
1
2
1
1
8
1
1
4
3
77
Clinical Incidents- without Severity Assessment Code
Clincal incident without Sac rating (n=6)
SAC
(blank)
Clinical Management
Medication/IV fluid;Clinical Management
Obstetric - Foetal;Clinical Management
Obstetric - Maternal;Clinical Management
Obstetric - Maternal;Documentation
Organisation Management/Service
MCRM Report September 2015
Page 3
Around the District
1. IIMs without a sac rating: 6 this month and 13 last month.
2. Implementation of Pertussis vaccination clinic
3. Audit Safer Sleeping practices for newborn- external auditor to conduct audit in all maternity
units end October 2015. Managers and Educators have received the data from the 2014
audit review, should be in the process of implementing the recommendations and
facilitating the process for all staff to view the education package in ppt format.
4. MEGs & education provided to clinicians at non maternity sites
MCRM Report September 2015
Page 4