WSLHD Lessons Learned

Western Sydney Local Health District

Clinical Administration

Latest Lessons Learned

7 Jul 2016 Improved Communication with Family and Carers
A 56-year-old man who had a disabling brain injury and epilepsy since birth was brought to hospital in the middle of the night for treatment of vomiting and pneumonia.
7 Jul 2016 Improvements Made to Ensure Safer Transfer of Care
A middle aged man arrived by ambulance to the Emergency Department after a fall in the Nursing home where he lived.
4 Mar 2016 Changed Processes after a Focus on Trauma Misses Infection
A man came into ED with injuries to many parts of his body. He was experiencing pain and coughing up blood. Later analysis of the case determined that staff focused on the man's trauma symptoms and had not appreciated his total clinical picture.
4 Mar 2016 Changes Result from Medication Missed
After her heart operation, a patient was not given a medication that should normally be given.
18 Jul 2014 Revised Protocols following a Patient Death
After a prostate operation, a patient was feeling unwell. Further investigation revealed Deep vein thrombosis (DVT) resulting in blood clots in both lungs