the dudley group of hospitals nhs trust - Dudley Primary Care Trust

4. The root cause analysis should be used to indicated whether the infectionwas avoidable and if there were any contributory factors. These should beclearly identified on the RCAs5. The Matron and Medical Service Head are responsible for ensuring theRCA and action plan is completed in the timescales.6. The RCA and action plan should be sent immediately to the NursingDirector/ Director of Infection Prevention and Control and the ConsultantMicrobiologist for onward reporting.7. The action plan addressing the main findings, themes and lessons learnedshould be implemented8. The RCA and action plan should be presented to the Clinical UnitManagement Team by the consultant and lead nurse and reported to thefollowing at the next available meetings:a. Infection Control Committee – presented by the Clinical Championsb. The Patient Safety Committee – presented by the Matron andMedical Service Headc. The Integrated Governance committee – as part of the PatientSafety report at the next meetingd. Trust Board – by the Director of Infection Prevention and Control(DIPC) / Governance Lead at the next meetinge. PCT / Strategic HA – by the DIPC by 15 th of each month.f. As part of MESS data – by the Consultant Microbiologist9. The Medical Service Head and Matron are accountable for the MRSAbacteraemias in the clinical unit and are responsible for monitoring theimplementation of the action plan and for reporting through the GovernanceStructure to the Integrated Governance Committee.10. Where a MRSA bacteraemia is noted to be a pre-48 hour infection (patientis clinically symptomatic and tests +ve within the first 48 hours ofadmission) in addition to the abovea. The DIPC will notify the Clinical Governance Lead/ Director ofPerformance and Quality for the relevant PCT.b. Trust staff will work with the Commissioning PCT whoseresponsibility it is to undertake a more in-depth investigation into thecausative factors.11. The Nursing Director/ DIPC, Chief Executive, Medical Director and Directorof Operations will meet on a weekly basis to review all matters related toMRSA bacteraemias.12. The Nursing Director and Consultant will ensure the Chief Executive isassured that all data submitted to MESS (Mandatory Enhanced MRSAsurveillance) is accurate and timelyInvestigation of Other infectionsRoot Cause Analysis following the Trust’s general procedure should beundertaken• Infection control ward outbreaks – MRSA, Clostridium difficile, otherorganisms on advice of the ICT• Serious Infections related to invasive devices• Serious infection on advice of ICT