Annual Report and Accounts - The Great Western Hospital

Following the Trust’s merge in June, the community arm of GWH is still reporting a large quantity of
their incidents on paper incident reporting forms which are subsequently input to the GWH electronic
system. Whilst all incidents reported in this manner are reviewed and reported within accepted
timescales, there is currently a three month backlog of inputting the data from these forms which is
reflected in the graph above. There is an ongoing community rollout of access, and training to the
GWH electronic reporting system. Wiltshire community users will be integrated onto the GWH
incident reporting system by September 2012.
TABLE - Top five clinical incident causes 2011-2012
Incident Cause
Grand Total
Fall - Found On Floor 933
Pressure Ulcer 607
Fall - Slip Or Trip 418
Equipment/Device - Contamination 258
Med Error - Missed Medication 226
Note - Equipment/Device – Contamination relates to damaged packaging on sterile equipment stored
for use. These are mainly ‘near miss’ incidents where the damaged packaging was found on routine
checks and alternative sets supplied for use.
Patient Falls and Pressure Ulcers are included in the South West SHA Patient Safety and Quality
Improvement Programme, which the Trust is currently participating in order to embed processes
focussed on reducing harm from these events.
Last year it was reported that there had been an increase in documentation errors but this trend does
not appear to have continued in 2011/12. The previous rise may have been due to the increase in
total reporting figures; the NPSA agree that organisations reporting more incidents generally have a
better and more effective safety culture. In the most recent NPSA Organisation Patient Safety
Incident Report, the GWH was in the highest 25% of reporters. Timeliness of reporting is also an
indication that the organisation is able to identify and act efficiently on incidents. The NPSA Report
from April to September 2011 recognised the Trust continued to submit 50% of incidents fewer than
20 days after the incident occurred, ahead of the average of fifty percent of all incidents submitted
more than 36 days after the incident occurred.
The volume of reporting within the Trust has continued to increase year on year:
• 3759 reported during 2009/10
• 4613 reported during 2010/11
• 5547 reported during 2011/12* *this includes the merged organisation from June 2011.
The NPSA Organisation Patient Safety Incident Report demonstrates that our rate of moderate harm,
severe harm and incidents resulting in death is over 50% lower than that of comparable trusts.
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