Annual Report and Accounts - The Great Western Hospital

No. Audit Title
Audit Summary/Learning and Action
23. Hip Resurfacing This Review was undertaken following Medicines and Healthcare products
Regulatory Agency
(MHRA) Alert- Revision of MoM (Metal on Metal) hip replacements. The
concerns involved soft tissue reactions which may be associated with
unexplained hip pain. The Orthopaedic Department categorised the
affected patients with plans to follow-up patients.
24. NICE CG56 -
Ordering of Scans
in Paediatrics
Incorporating
Head Injury
Results demonstrate compliance with the NICE guidance and that there is
appropriate ordering and undertaking of CT Scans.
25. Neonatal
Readmissions to
the Children's
Ward 0-28 Days
of Age
26. SALT (Speech
and Language
Therapy) - Service
Evaluation of the
interface between
agencies
supporting
children with
Autistic Spectrum
Disorders (ASD).
27. Venous
Thromboembolism
(VTE)
28. Induction of
Labour
29. VTE Assessment
of Screening
Prophylaxis
30. Delayed and
Omitted Medicines
Audit
Results reflect good communication of breastfeeding care. Actions
include- Infant coordinator to continue in-house training. Use of
Breastfeed observation charts to pick up ineffective feeding at an earlier
stage.
Actions include improved sharing of information using Communication
Assessment Form and better communication between the SALT Service
and other multi-agencies.
The results demonstrated that overall compliance was very high. Actions
include possibility of using a sticker stating the VTE assessment at each
ante natal admission.
There was low compliance with documentation of the discussion with the
mother about induction of labour in the maternal records. Actions include-
Remind all midwives of the importance of discussion of prolonged
pregnancy and induction of labour and giving leaflet to supplement these
discussions.
The results reflected very high compliance with the majority of criterion.
Actions include all blank missed doses to be reported to the Ward
Manager and investigated.
31. Death Certificate
Completion
Areas for improvement identified were recording of Doctor’s grade and
name, training and education and guidance notes that include clarification
on confirmation and certifying deaths.
32. End of Life Base line audit results demonstrate that the Trust performance is better
that the nationally published data. Actions include- discussion of results
with the Commissioners to agree a CQUIN target.
33. Compliance with
Joint Guidelines in
Regard to
Overall compliance is excellent. Further actions include educating
prescribers to ensure patients are switched from Intravenous to oral
antibiotics.
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