https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3 en-us 2022-06-16 05:25:08 UTC 2026-02-24 04:47:13 UTC hello@padlet.com https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2273658131 An incident report was placed because approximately 90 patient procedures that were recorded on an endoscopy machine were wiped accidentally. While reports for the procedures were available the lack of raw data and ability to review these procedures with ENT was very problematic and concerning that this could happen again. Unfortunately despite my manager encouraging the incident report, there was not much action or followup organisationally to look at how this could be mitigated in the future. But more disappointingly was that this was patient data and I felt like there should have been some disclosure to affected patients that this had occurred - particularly as they were in their rights to request a copy or ask to review it with the clinician for feedback. It got worse when a code brown hit and the safety department deemed it ok to wipe / close all ISR3 and 4 incidents with the reason sited - due to code brown - NO FOLLOWUP. I'm clearly still riling over it! ]]> 2022-08-28 06:29:03 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2273658131 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2273658402 Following an incident report submitted after a MET call for a patient there were some significant actions identified to help manage any future similiar situations and equipment purchased and processes established as a result. This was pleasing that things were acted upon. ]]> 2022-08-28 06:30:17 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2273658402 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2274415923 An incident report was made a couple of months ago when a patient was admitted from emergency (where she had been for several hours being treated) and placed into a 4 bedroom room in preparation for surgery later in the afternoon. After a few hours one of the ward nurses went to prepare the patient for surgery and to do a pre-surgical rat test to which they responded "but I already know I am covid positive because I've been caring for my son who has it at home"...we were horrified that they had been in the hospital for so long and did not tell anyone prior. All of the patients in her room were then put in isolate as close contacts and the patient was transferred to our covid ward, incident reports were made and now all patients must be covid tested prior to admission. ]]> 2022-08-29 07:13:23 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2274415923 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2274418325 We reported an elderly confused patient who was found wandering off into other peoples rooms at times, we were able to get extra staff and open a "COB" room which is a close observation bay where the nurse must be in the room at all times to keep a close eye on confused or high falls risk patients to prevent further incidents similar. ]]> 2022-08-29 07:15:48 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2274418325 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2277104602 I had a patient who'd had a stroke, it was particularly busy in the ED, and one of our orderlies asked if a different pt could go to the bathroom, I said yes, she let the bed side rail down on the stroke patient, who promptly fell out of bed and did her NOF. Riskman completeted, pt went to threater, nothing happened to the orderly, rather, i had a please explain. Safe to say I dont let this orderly near patients anymore.]]> 2022-08-31 02:25:06 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2277104602 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2281372220 I was a new employee pharmacist and had a complaint made against me. An apparently regular patient came in requesting Chlorsig eye drops for his sore eyes, which he described to me as watering and with a pain scale rating of 10 out of 10, he also had an aversion to bright light. I refused supply of the chlorsig and referred him urgently to the hospital, and offered to call an ambulance if he couldn't get there himself. He was upset at me, offered some abuse along the lines of 'you're denying me treatment, it's always worked before' and left. He wrote an extensive letter of complaint to my new manager, who spoke to me about the incident and provided a response to the patient in support of my actions, but that she would be happy to chat to him about it.

It was nice to have that support from my manager, and to know that she will consider all sides of the story before responding to any feedback.]]> 2022-09-03 06:55:25 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2281372220 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2281425793 I have been involved in writing and creating incident reports in my workplace. I have often found the process well outlined and incident reporting software and systems are intuitive and easy to use, however, the outcomes are not very well understood. Lessons learnt and incident reporting outcomes do not get communicated further down the line, so we often do not know what outcomes or impact such reporting measures have other than ticking some KPI boxes higher up which becomes problematic because we then don't see the value of putting in the effort to report the incident to begin with.]]> 2022-09-03 10:03:16 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2281425793 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2287450393 An incident report in relation to stage 2 pressure injury was logged. The manager blamed the reporter had made wrong comment on wound type and it had been corrected by the manager. The trigger of the manager's reaction is that the Aged care quality and safety commission wound not be satisfactory with wound management when pressure injury is identified at later stage. Though the wound type was identified, documented and treated as stage 2 pressure injury in the end, it made the staff reluctant to make incident reports, which resulted in incidents under reporting.]]> 2022-09-08 02:39:59 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2287450393 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2287742936 A patient was held from arriving into PACU due to lack of nursing staff- although space was available. The surgeon arrived into the unit and proceeded to take photos of the staff and patients within PACU. When asked to stop and delete photos due to confidentiality and lack of consent- they become verbally abusive, screaming and needing escorting out of the unit by an anaesthetist. An incident report re the photo and abusive behaviour resulted in an immediate response from both Directors of Nursing and Head of Surgery where said surgeon was interviewed, photos deleted, and placed under performance management for behaviour. The entire response occurred across the space of 2 hours post incident. ]]> 2022-09-08 07:06:12 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2287742936 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2287756327 Not so much a negative from direct reporting but a negative outcome from pressures as a manger to complete investigations and close out incidents in short time periods. The response times are logged for when a incident is reported, to when it is viewed, to when it is being investigated, and the eventually closed with a manager summary/recommendation. As incidents can accumulate and investigations take time, the pressure from system managers to close incidents to ensure compliance, can override the benefits of reporting - to learn and improve. At times there are missed opportunities to fully explore why an incident has occurred or the development of a pattern.]]> 2022-09-08 07:17:45 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2287756327 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290912395 I was new to the role and found out few missing activities and evidences for risk assessment and consent/authorisation attached to consumer care plans. I have reported this to the DON and was surprised that all of this are not payed attention.]]> 2022-09-11 02:31:40 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290912395 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290912941 The negative report I had encounter with reporting was some of the staff involved and supposed to be doing this task had seemed to be upset that this was sighted and noticed.]]> 2022-09-11 02:33:27 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290912941 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290920969 Two staff members fighting in the corridor over staffing concerns in front of patients, both patients requested to put in complaints about the unprofessional behaviour. As requested, I helped them. Nothing happened to the staff, no sorry to the patients from these staff members. It seemed to be al swept under the rug. I did bring it up with management and I was told, 'its being investigated' . Two years on and I never heard anything about it again. Makes you feel making complaints is pointless in these cases. ]]> 2022-09-11 02:56:53 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290920969 14327872 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290948539 We had a case of CRE that was missed. The patient had been through the ED, 2 different wards at 2 different sites of the same health service. A riskman was completed and I (as the manger of one of the wards) got a please explain from the IPAC team as to why the Nurses didn't think of CRE when the pt had been overseas. It was automatically assumed the the reason for missing the CRE is because the nurses needed more education. I was so angry that the blame was being pointed at the nurses. I explained, that IPAC are subject matter experts so in hindsight it was easy for them to think the pt had CRE when reading back through all the notes, but its unreasonable to think a bed-side nurse would automatically consider CRE just because the patient had been overseas. I asked for an in depth case review as I felt it was a system wide issue as the pt had been through multiple wards, departments and teams and no one thought of CRE, yet my nurses got the blame. a RCA proceeded and multiple system wide issues were identified and since then multiple system wide recommendations have been implemented, with one low impact recommendation being nurses receive education, yet initially this was the only focus/recommendation. ]]> 2022-09-11 04:27:10 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2290948539 https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2291424076 I was transitioning from HDU to ICU nursing and was meant to be on my 2nd supernumerary day of looking after an intubated patient. However due to short staffing I was taken off supernumerary (I was meant to have two weeks of supernumerary before looking after patients by myself) and I was given a "HDU" level patient within the icu. Understandably I was very flustered, overwhelmed and quite frankly very annoyed. This resulted in misreading a medication order and I administered 1 vial of an IVAB instead of 0.1 of a vial as the order stated. I entered an incident report detailing the poor staffing and poor training leading to the error and received no feedback from my manager or anyone ]]> 2022-09-11 21:21:50 UTC https://padlet.com/postgraduate_futures/9mymdpb1cxoy8oq3/wish/2291424076