Quality Account 2010/11 - James Paget University Hospitals

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Never Events Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. The core list of Never Events for 2010/11 is detailed. This has been increased to a list of 25 for 2011/12: • Wrong site surgery • Retained instrument post-operation • Wrong route administration of chemotherapy • Misplaced naso or orogastric tube not detected prior to use • Inpatient suicide using non-collapsible rails • Escape from within the secure perimeter of medium or high secure mental health services by patients who are transferred prisoners • In-hospital maternal death from post-partum haemorrhage after elective caesarean section • Intravenous administration of mis-selected concentrated potassium chloride. The Trust has introduced a number of control measures to prevent Never Events from occurring. However, during 2010/11 there were two Never Events, both of which involved the retention of a small swab following suturing after an instrumental vaginal delivery. A detailed programme of training, awareness and checklists has now been introduced to prevent a similar occurrence in the future. An audit will be conducted during summer 2011 to ensure these improvements have been embedded into practice. Case Study: Patient Fall (SUI) Incident: Patient found on the floor beside the bed having been recently transferred from the admissions unit (within one hour of transfer). Patient was diagnosed with a fractured neck of femur (broken hip). The family were informed and the incident was investigated formally using Root Cause Analysis techniques. Findings: Patient was transferred into the ward at lunchtime when staff were busy with medicine administration and feeding patients, hence all falls prevention options were not considered upon admission. Improvements: Patients at high risk of falls are now cohorted into one bay and staff are allocated to monitor the patients (additional staff are booked). Staff are encouraged to consider the use of falls prevention equipment such as falls beds and sensocare equipment. Falls risk assessments are conducted on admission and then weekly; each bay has an allocated day for the assessment to be completed which is advertised at the end of each bay. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 42 of 62
Patient Safety Alerts At the time of this report the Trust is compliant with all patient safety alerts which are monitored by the Central Alert Service. The Trust has a robust process in place for ensuring that alerts are received and circulated to the relevant individuals promptly so that any necessary actions can be taken within the timescales prescribed. NHSLA and CNST The Trust was assessed and achieved NHS Litigation Authority (NHSLA) Level 2 in May 2008. The Trust will be reassessed against the 2011/12 standards for acute trusts in early May 2011 when it is hoped that Level 2 will be retained. The Maternity Service was reassessed in March 2011 against the Clinical Negligence Scheme for Trusts (CNST) 2010/11 Maternity Standards. The service achieved Level 2 against these standards. Clinical Outcomes and Effectiveness Accountability Framework – Nursing Care Metrics A key piece of work undertaken by the Chief Matron and the Patient Safety Project Director, to support the aims of the Patient Safety project, has been the development of an Accountability Framework for nursing staff. The primary aim of the framework is to provide clarity for staff regarding the standard of practice that is expected. Secondly, that any variation in the standards of care our patients receive will reduce, and our organisational and departmental approaches will become appropriately standardised. The framework consists of 15 Care Metrics within which there are 77 evidence based Key Performance Indicators (KPIs). Performance is monitored on a monthly basis via audit data collection. Feedback is provided to the relevant Ward Manager and Matron. The first audits took place in November 2010 and this data has been used as the baseline. As expected, the first set of results were variable amongst the different areas included. However, it is already evident that Ward Managers are embracing the concept of the framework as a tool to strengthen their team’s performance and capability to improve patient outcomes. Once we have established and embedded the Nursing Accountability metrics and KPIs into practice we will introduce a further set of metrics at ward level that will reflect other patient sensitive areas where Allied Health Professionals and medical colleagues lead e.g. medicines management and documentation. In addition we need to ensure that the Nursing Accountability Framework links clearly with the Divisional performance score cards and performance meetings led by the Director of Finance and Performance. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 43 of 62
Page 1: James Paget University Hospitals NH
Page 4 and 5: Contents Page Foreword by Chief Exe
Page 6 and 7: The old and the very young are know
Page 8 and 9: Statement of directors' responsibil
Page 10 and 11: Current position: Patient Falls 120
Page 12 and 13: Priority 1b: Patient safety - Reduc
Page 14 and 15: Five work streams have been agreed
Page 16 and 17: No Commissioning for Quality and In
Page 18 and 19: No Commissioning for Quality and In
Page 20 and 21: The services provided by James Page
Page 22 and 23: Clinical Audits Audit Name Applicab
Page 24 and 25: (NHSBT UK Transplant Registry) Audi
Page 26 and 27: Case Study 2: Upper Gastrointestina
Page 28 and 29: The Trust has a dedicated lead for
Page 30 and 31: NHS number and GMC code validity Ja
Page 32 and 33: What others say about the Trust Car
Page 34 and 35: Current Position: Inpatient Pressur
Page 36 and 37: Metric 3 - Venous Thromboembolism (
Page 38 and 39: Monthly CVC BSI Rates 14 12 Rate of
Page 40 and 41: Metric 8 - Nutrition & Hydration Ma
Page 42 and 43: Patient Safety Incidents As at 18 t
Page 46 and 47: Existing Commitments and National P
Page 48 and 49: Patient Experience National In-pati
Page 50 and 51: An action plan has been developed f
Page 52 and 53: Maternity National Survey The respo
Page 54 and 55: Question Area Conclusions Recommend
Page 56 and 57: Case Study: Health Service Ombudsma
Page 58 and 59: Patient Experience Measures Patient
Page 60 and 61: • 100 Key Scores Comparison 90% 8
Page 62 and 63: NHS Great Yarmouth & Waveney NHS Gr
Page 64: Glossary of Abbreviations A&E C dif

Quality Account 2010/11 - James Paget University Hospitals

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