Annual Report and Accounts - The Great Western Hospital

The three top serious incident causes and their report recommendations are;
• Patient Falls
o Variance on audit compliance - Falls risk assessment and SAFE tool. Monthly audits
undertaken to monitor compliance;
o Reinforcement of the importance of implementing care plans following identification of
at risk patients;
o Improving and cascading information to all members of the Multidisciplinary team
• Community acquired grade 4 pressure ulcer
o Immobile patients to receive multi-disciplinary care planning;
o Regular review of nutritional status;
o Improve recognition, and subsequent referral when patients current pain-relief regime
is not sufficient;
o Patients identified as being at risk of or who have pressure ulcers will have core care
plans that are implemented and regularly evaluated;
o Monitoring accuracy of assessments; additional training identified and accessed
• Ward Closure
o Improve staff awareness of procedure and policy surrounding isolation, control and
investigative procedures of possible outbreaks of infection;
o When outbreak identified, check possibility of cross contamination of patients exposed
and discharged from affected area;
o Ensure full and accurate patient details are given when transfers are planned.
o Hand hygiene audit completed weekly
o Personal protective equipment to be available and staff reminded of when to wear.
Presentations of the reports of these investigations are made to Directorate Leads at the monthly
Patient Safety and Quality Committee meeting; learning from this, including action plans is then
cascaded to directorate teams to share good practice. Utilising this system of reporting enables the
Trust to learn from incidents, complaints and claims and act in a proactive way to try and prevent
similar events occurring.
National Patient Safety Thermometer.
During 2012/13 the Trust will adopt the NHS Safety Thermometer; developed for the NHS by the
NHS as a point of care survey instrument. The survey allows teams to measure harm and the
proportion of patients that are ‘harm free’ within their care. Survey measurements will be uploaded
onto a national monitoring tool to allow organisations to benchmark against others.
The four areas being measured are:
• Pressure ulcers;
• Falls;
• Urinary catheters and associated infections;
• VTE assessments.
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