Annual Report and Clinical Governance Report 2008 to 2009

Table 2 indicates where there has been a large focus on reporting under various
aspects of the adverse event framework.
Adverse events reviewed by the clinical governance team were to found to have
been managed appropriately by staff at the time. By taking a systematic approach
to recording and assessing adverse events as part of the clinical governance
framework we are able to identify existing systems and processes that are less than
satisfactory and make the necessary changes.
Sandyford staff are updated quarterly on adverse events and updated on any
changes that have been made. As these meetings are quarterly we recognise that
we need to communicate to staff more regularly with regards some adverse events
and achieve this through our e-bulletin which is sent to every staff member in the
organisation fortnightly. Communication to staff is vital to the success of continued
adverse event reporting as it gives staff ownership of the process and demonstrates
where action has been taken.
Adverse events in context
This is an opportunity to draw together a number of adverse events that have
occurred within the organisation and some of the actions taken. Examples of
adverse events will be highlighted under each of the factors as identified by the
adverse event framework.
Client Factors
Verbal Aggression (19 reports)
As stated earlier through adverse event reporting we were able to record verbal
aggression from clients and part of our response to this was conflict management
training. In addition to this our program system (Clinic Pro 2 and then from
December 2009 the NaSH system) enabled us to ‘flag’ clients who were noted to be
verbally aggressive to highlight to staff should the client access the service again
and also monitor where individual clients were persistent. This coincides with the
Scottish Government and NHS Greater Glasgow & Clyde policy of zero tolerance of
verbal aggression towards NHS staff.
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