Royal Victoria Hospital, Belfast - 17 July 2012 - Regulation and ...

Reference
number
Recommendations
Designated
department
Action required
Date for
completion/
timescale
requirements. This process supplements
the existing audit tools used by PCSS, IPC
and also existing external audits conducted
by Daniels (sharps box suppliers).
Daniels’ audit completed Oct 2011 and
results disseminated.
13. The trust need to review staff practice in relation to
the administration of medications and provide training
if required.
Nursing
The administration of medications is a
statutory and mandatory training
requirement for nursing staff.
Ongoing
The administration of medications is in the
annual mandatory training study days and
staff are required to complete pre-course
information prior to attendance. Staff must
adhere to the Trust’s Medicines
Management Code.
14. The trust and individual staff have a collective
responsibility to ensure that equipment is clean,
stored correctly and in a good state of repair.
Nursing
PCSS
IPC
Work / negotiations in relation to the
cleaning manual are still ongoing. In
particular, there is discussion with
nursing/control of infection with reference
bed cleaning. Once agreement is reached
the manual will be finalised.
Ongoing
The manual includes roles and
responsibilities of trust staff in relation to
patient equipment. A template will be used
to record all cleaning of equipment.
Staff have been reminded of protocols in
relation to sterile items.
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