Annual Report and Accounts - The Great Western Hospital

Safe care of the patient receiving blood component transfusions has been regularly monitored via
audit of transfusion observations. Minimum monitoring of the patient should include temperature,
pulse, blood pressure and respiration rate. These should be recorded no more than 60 minutes prior
to commencing the unit, 15 minutes into the unit (this includes observations undertaken within a 5
minute window either side of the 15 minutes) and no more than 60 minutes after completion of the
unit. This is stipulated within the Trust’s transfusion guidelines and will be monitored via audit at least
once a year.
The National Patient Safety Agency (NPSA) competency based training for blood administration and
venepuncture continues. The Trust is working towards achieving the set target of 100% for all staff
involved in transfusion. However this is a very fluid process due to staff leaving and joining the
organisation, maternity leave, long term sick leave etc. Staff who do not have a current relevant
competency can no longer perform the procedure. Work is ongoing to monitor transfusion related
competencies. A clear process of action was approved utilising the Matrons actively in policing and
managing staff competencies. A ‘transfusion breech form’ is generated whenever blood is
administered by someone who, according to our records, does not have the relevant competency.
The number of breaches is falling month on month which shows that we are making good progress.
Priority 6: To Reduce Preventable Hospital Mortalities
Hospital Standardised Mortality Rate - The Trust has maintained an aggregate 98.7 Hospital
Standardised Mortality Rate (HSMR) below (better than) 100 for the year to date (April – February).
The graph below shows how the Trust is performing when compared to the average for the South
West SHA and against the national expected level of 100. It can be seen that over the last 13
months the Trust’s trend has broadly followed that of the SHA average although at a higher level with
some peaks.
CHART – Hospital Standardised Mortality Rate GWH and SHA most recent 13 months
120.0
HSMR Mortality GWH and SHA - Most Recent 13 Months
110.0
100.0
90.0
80.0
GWH
SHA
70.0
Nat Expected
60.0
Feb-11
Mar-11
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
The graph below shows in more detail how the Trust compares against the other Acute Trusts in the
SHA for HSMR relative risk for the current year. It can be seen that performance is generally good in
the SHA.
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