332 results for “emergency patient transfer”
75y · Male·Multi-organ failure secondary to cardiogenic shock and anterior myocardial infar…
…ure to escalate despite diagnostic ECG changes; delayed CT aortogram (ordered to exclude dissection); and transfer to the 'cold' zone of ED despite evolving STEMI. PCI was eventually performed >10 hours post-symptom onse…
45y · Female·Aspiration pneumonia
…ore attendance (6:30 pm to 4:00 am). She was admitted to hospital on 3 January with aspiration pneumonia, transferred to ICU on 4 January, and died on 5 January despite antibiotics and non-invasive ventilation. The coron…
83y · Female·cardiac arrest from severe triple vessel coronary artery disease complicated by …
…rural settings; treatment plans must be reassessed when ineffective; and systemic staffing is critical to patient safety. The coroner found no individual culpability but identified systemic problems subsequently address…
55y · Male·Multiorgan failure and septic shock complicating parasitic gastrointestinal infe…
… On 16 July, diarrhea with visible worms and systemic signs (tachycardia, hypotension) prompted ambulance transfer. He was diagnosed with sepsis of unknown origin at hospital but deteriorated rapidly despite antibiotics.…
34y · Female·multiple blunt force injuries
…4, died by suicide at Echo Point Lookout in the Blue Mountains hours after discharge from mental health inpatient care. She had complex borderline personality disorder with chronic suicidality across 20+ hospital admiss…
87y · Female·right thigh haematoma as a consequence of a periprosthetic fracture of the right…
…n was a contributing factor. Key lessons: earlier recognition that rehabilitation was unrealistic; timely transfer back to tertiary hospital for enteral nutrition; earlier goals-of-care discussions; and improved nutritio…
0y · Male·Sudden Infant Death Syndrome (SIDS) against a background of sub-glottic stenosis…
…nt with sub-glottic stenosis from prolonged neonatal intubation, died suddenly in his parents' car during transfer home from Brisbane to Tully. The stenosis had been investigated and deemed clinically insignificant. The …
81y · Female·ischaemic bowel
…ntal Health Act detention. On 9 May 2009, her physical health acutely declined with shock-like symptoms. Emergency laparotomy revealed extensive bowel ischaemia deemed incompatible with life. She died the following morn…
62y · Male·Self-inflicted intentional hanging
…. Key clinical lessons include improving communication between administrative and medical staff regarding patient risk indicators, ensuring security-relevant information is promptly conveyed to treating clinicians, and …
0y · Female·hypoxic ischaemic encephalopathy secondary to intrapartum hypoxia
…gela Willmett, died from hypoxic-ischaemic encephalopathy following intrapartum hypoxia. She was born by emergency caesarean section after a planned vaginal birth after caesarean (VBAC) at a country hospital. Critical f…
72y · Male·hypovolemic shock due to haemoperitoneum following surgical repair of an abdomin…
…h anticoagulation and antiplatelet agents. Critical failures included: non-provision of clinical notes at transfer, failure to seek surgical review despite recent operation, and failure to reconsider diagnosis despite mo…
72y · Male·Cranial fracture and intracranial haemorrhage from self-inflicted fall
… when he deliberately threw himself backwards onto the floor of a psychiatric ward. He was an involuntary patient in the High Dependency Unit experiencing acute psychotic relapse with command hallucinations. Clinical st…
84y · Male·Complications of large right subdural haematoma
…istant in nursing (AIN) was absent obtaining equipment. The AIN had raised the bed to facilitate use of a patient lifter, contrary to falls prevention policy requiring low bed positioning. No crash mats were present. Wh…
48y · Female·Cardiorespiratory arrest due to cardiac tamponade as a result of perforation of …
… perforation of the right atrium during central venous catheter exchange in ICU. She was recovering from emergency liver transplantation complicated by sepsis and acute renal failure. A routine guidewire exchange of her…
45y · Male·aspiration pneumonia secondary to left middle cerebral artery infarct complicate…
…(slurred speech, tongue deviation, facial droop, headache), and appropriately called an ambulance. He was transferred to Royal Adelaide Hospital where stroke was confirmed. Despite appropriate medical treatment, his cond…
33y · Female·multiple injuries sustained in a train incident
… died by suicide after stepping in front of a train on 6 October 2009. She was an involuntary psychiatric patient at Northpark Private Hospital despite confusion about her legal status. She left the ward opportunistical…
41y · Male·haemothorax due to ruptured thoracic aortic aneurysm in a man with Marfan syndro…
…focus on improving communication of security information between facilities, creating alerts for security transfers in the management system, and developing end-of-life planning policies including Do Not Resuscitate proc…
25y · Male·consistent with drowning in a man with multiple injuries
…l communication failures occurred: the morning shift staff were not informed of the ECATT assessment, the patient's labile mood, or RPN Harris's advice that he might need HDU transfer if presentation changed. No psychia…
53y · Male·Metastatic pancreatic carcinoma
…ommunication blackout with family in remote location; (4) no clinician proactively contacted family after transfer to Prince of Wales Hospital emergency department; (5) inadequate systems for documenting and communicatin…
87y · Female·Complications of head injuries and left proximal femur fracture sustained in a f…
…medical review (locum failed to attend) and failure to consider alternative escalation pathways (Virtual Emergency Department, senior staff consultation) resulted in 18-22 hours without clinician assessment; (5) the Med…
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