Annual Report and Accounts 2012/13 - Royal Bournemouth Hospital

Quality ReportTable: Patient safety incidents reported to NPSA via the nationalreporting and learning system - April 2012 to March 2013Severity of Incident ReportedTotalNumberReported2012/2013% ofIncidentsReported2012/2013TotalNumberReported2011/2012% ofIncidentsReported2011/2012No Harm 3415 56.8% 3115 60.7%Minor / Low 2451 40.8% 1834 37.5%Moderate 115 1.9% 150 2.9%Major / Severe 30 0.5% 31 0.6%Catastrophic / Death 0 0 0 0Total: 6011 5130Nationally 0.8 % of patient safetyincidents reported to the NationalReporting and Learning System arerecorded as having caused severe harmor death. The Trust’s percentages forboth 2011/12 and 2012/13 are muchlower at 0.6% and 0.5% respectively.Examples of changes made as a resultof incident investigations this year haveincluded:l Staffing templates reviewed onwards and increased where requiredto ensure safe staffing levels areprovided for all shiftsl Funding for earlier use of heelprotection approved and new clinicalguideline implemented to support usel New protocols for gastrointestinalbleed patients have been developedand an update provided at a medicalgrand round meeting and in the juniordoctors’ teaching programl New system of checking anaestheticmachines implemented and newelectronic system of recording andfollowing up on missed checksestablishedl New standard operating procedures inpharmacy for dispensing of medicinesand new training programmesintroduced. There are also newposters in pharmacy dispensing areato alert patients to the importantprocess of identity checking prior todispensing medicationMedication safetyThe Trust’s Medicines GovernanceCommittee is chaired by the MedicalDirector and its remit is to enhanceand monitor the Trusts strategyto reduce medication errors,compliance with national standards formedicines management and ensuringimplementation of safe practice alerts andreports.The Trust’s Medication Incident ReviewGroup is chaired by the Deputy Directorof Nursing and Midwifery. It ensuresthat Directorates take responsibility forreviewing incidents involving medicines,sharing learning and initiatives to improvesafety and reduce risk.In 2012/13 a total of 753 medicationrelated adverse incidents were reportedand investigated. This is an increasefrom 2011/12 (679) and 2010/11 (509)and reflects the Trust’s commitment toencouraging open reporting.Of the 753 adverse incidents reported73% represented no harm events. Thisis consistent with previous years’ results(2011/12 - 75%, 2010/11 - 73%).74Annual Report and Accounts 2012/13