Quality Account 2010/11 - Royal Marsden Hospital

The Royal Marsden NHS Foundation Trust
Table 5: National Confidential Enquiries reports published in 2010-11 and actions
No
National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) studies
Description of actions (local)
1 Elective & Emergency Surgery in the
Elderly: An Age Old Problem (2010)
No change in practice
2 Cosmetic Surgery: On the face of it (2010) Not relevant to the Trust
3 Parenteral Nutrition: A Mixed Bag (2010) Adoption of self-assessment checklist
under consideration. Audit of nutrition
on the critical care unit underway
The reports of 66 local clinical audits were reviewed by The Royal Marsden in 2010-11 and The Royal
Marsden intends to take the following actions to improve the quality of healthcare provided.
Table 6: Local clinical audits undertaken and reports received during 2010-11
No Clinical Audit Title Description of actions
1 An audit into the optimal use of ambisome
as a treatment agent based on highresolution
computed tomography (HRCT)
criteria in patients with acute leukaemia
Best practice confirmed.
2 Single-sex accommodation audit If a breach occurred staff review the
case to identify points of learning
and escalate immediately
3 Comparison of Radiology reporting pre
and post proforma introduction, GI 108
4 Audit of accuracy of patient
positioning for radical pelvis
(colorectal) radiotherapy, GI 089
5 Audit of outcome following the introduction
of the 2-week rule for lung cancer, LUN 066
6 K-ras genotyping and second line
therapy for Non Small Cell Lung
Cancer (NSCLC), LUN 078
7 Fractionated stereotactic radiotherapy
(FSRT) in the treatment of vestibular
schwannoma (acoustic neuroma): Predicting
the risk of hydrocephalus, NEU 066
Confirmed value of using proformas. Proforma
reporting to be adopted nationally.
Patients should be lying on their back during
treatment if and when the intensity modulated
radiotherapy technique is to be implemented.
Addition of performance status to electronic
templates for producing clinical diagnosis
and treatment letters to be explored.
Development of a bronchoscopy
service for repeat biopsies.
Treatment now starts when a lesion
reaches 2 - 2.5 cm. The risk of developing
hydrocephalus linked to the radiotherapy
is to be highlighted to clinicians.
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