INCIDENT REPORT - From 1st NOV to 15th Nov 2011

Sl NO: DEPARTMENTS PERSONAL It was reported that the attenders were not found after 4:30 pm in endoscopy unit. Noticed that the staffs were going with giving handover. No incidents reported No incidents reported No incidents reported No incidents reported EQUIPMENT ENVIRONMENT

OPERATION THEATRE

2 3

CASUALITY RECEPTION Security

OUT PATIENT

At the time of dialysis, CBC report was observed that the total WBC count was very low. A fresh sample collected on the next day was reported to be LAB, X-RAY, ECG, CT increased SCAN, USS it has reported from ICCU that the urine p/c ratio reports which has been sent on evening got delayed and received the result at the next day night. ICCU No incidents reported

9 SICU

It was found that the ward nurse had given Inj Taxim to the patient and entered in the medication chart as Inj ceftriaxone It has reported very difficult to roster the staff nurse from the SICU to Recovery room at the time of more admission in Recovery room

A patient with the history of MI a known case of CAD, unfortunately admitted under Medicine. Cardiac patients coming through casuality were admitted to ICCU with reference of RMO were not taking responsibility till the concerned Doctor's visit. Nursing staffs are unable to convey the previous condition of the patient to the bystanders at any emergency situation.

10

ICCU

NICU

Pharmacy had found a medicine list of a patient without mentioning their name, OP no: The pharmacy staff asked the patient name to the bystander.

11

1st floor

Inj Fragmin 50000 BD were given against the order of Inj Fragmin 5000 BD OP no: of a patient written wrongly in the Doctors order

12

The order of the drug has been given as Ciplar 500 instead of Ciplox 500 It has been written as Cipl in the patient's case sheet. The order of the drug has been given as Ciplar 500 instead of Ciplox 500 It has been written as Cipl in the patient's case sheet. OP no: didnt mentioned in the Drug prescription 2nd floor (A+B) They only mentioned Vasofix 20 without mentioning the name of the drug Zonomax 1.5

2nd floor (A+B)

The nursing staff written Budamate Rotacap without mentioning the strength of the drug OP no: of a patient written wrongly in the Doctors order (2 times) The result of Na+ and K of a patient didnt informed to concerned Doctor and he noticed on the next day. The patient bystander complaint on the sound producing from the OT site. A patients bystander had behaved badly on unavailability of the water in the room side. The drug Eptoin which has been prescribed by the neurologist in which the staff nurse has not taken down the orders properly in the medication chart. The physician noticed on the next day, by that time; the patient had already missed 3 doses.

13

2nd ward

No incidents were reports

14

3rd cubicle ward

Patient of acute Ischemic strock was adviced Preva As Atrovastatin on 3/11/11and the staff nurse administered on the same day and missed to write the same on 4/11 and 5/11, hence patient didnt received these medications on those days Rats found repeatedly in the store room.

15

3rd room (A+B)

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DIALYSIS

Soap solution was filled and kept in the formalin can in the unit. It has been mistaken as formalin and filled in the filling cans. After filling the cans, it has been identified as soap solution and removed. It has prescribed 10 DNS instead of 1 from pharmacy pharmacy dept had found prescription without the order of ID band for the mother as well as child. Labour room door not working properly. So inside sound and patient crying sound are audible in outside. Curtain hanger get broken and fell down to the patient side. Nothing happened to the patient; but still there is no curtain in that place

17

LABOUR ROOM

20

CSSD

No incidents reported The physiotherapy room which is nearer to the Canteen Staff rooms. It was found that lot of noises and bad words with local communication which is getting disturbed to the patients in the department.

physiotherapy