Annual Report and Accounts - The Great Western Hospital

All the guidelines have been disseminated to the relevant clinicians and directorates including
Wiltshire Community Health Services. A response rate of 96 % or above has been maintained
throughout the year.
35/82 (41.5%) of the publications have been confirmed they are relevant to the Trust.
Out of this 35 -
• 22 guidance have been assured of full compliance
• 4 guidance’s are currently being implemented
• 6 have only recently been published and are within time frame to respond
• 1 Technology Appraisal is under discussion
• 2 guidance’s have been reported as an exception as the Trust has other provisions to
implement the guidance.
Thus Trust wide compliance of 98-100 % has been attained this year.
CAS: The CAS (Central Alerting System) publishes Safety Alerts, emergency alerts, Dear Doctor
letters and Medical Device Alerts on behalf of the Medicines and Healthcare products Regulatory
Agency, the National Patient Safety Agency, and the Department of Health. These relate to medical
devices, hospital facilities, equipment and clinical incidents. Responses and actions are monitored to
defined deadlines via a web based system. Between April 2011 and March 2012 the Trust received
112 alerts from the CAS system.
CHART – Central Alerting System Alerts 2011/12
CAS alerts ( MHRA, NPSA, EFA, DH) completed by deadline
100
% alerts closed by
deadline
95
90
Apr-11
May-11
Jun-11
Jul-11
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Target
% closed
by deadline
Date
The standard of at least 95% compliance with no significant exceptions has been maintained
throughout the 2011/12. Any alert that has failed to achieve full compliance within the
prescribed deadline is reviewed monthly at the PSQ meeting to ensure that progress is being made
to address outstanding actions and that no significant risks exist.
All alerts that are past, or within one month of, their deadline have an allocated lead manager and
associated responsible member of the executive, and outstanding actions are listed against expected
resolve dates. These alerts are risk assessed to indicate the level of risk associated with non
compliance.
The NPSA alert, 2010 RRR019: Safer ambulatory syringe drivers, is outstanding, awaiting
confirmation of a training programme in the community. Clinical Risk assesses the risk of non
completion to be low. There is one Estates alert past its deadline, EFA 2011/002, concerning the
management of refilling liquid Oxygen VIE plants. The outstanding actions concern approval of
documentation. Estates and Facilities Management assess the risk to be low.
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