Annual Report and Accounts 2012/13 - Royal Bournemouth Hospital

Quality ReportPatient safety and quality improvementInitiatives to support medication safetyand medication incident reduction during2012/13 have included:- Wards have completed medicinesmanagement self-assessment auditsand developed action plans to addressthe issues raised.- Wards have completed injectablesself-assessment audits with theirpharmacist and developed actionplans to address the issues raised.- Slam locks have been fitted to all ofthe medicines trolleys on the wards toreduce the risk of unauthorised accessto medicines.- Following a successful trial,pharmacists have attended posttake ward rounds for medicaladmissions since October 2012. Thiscontinues to show benefits in saferprescribing, reduction in missed dosesand reduced risk to patients frommedicines.- An audit of prescriptions for treatmentdoses of Low Molecular WeightHeparins (NPSA RRR014) wascompleted in October to December2012. The results and the need toimprove documentation and practiceis being discussed with the specialtiesand at educational meetings.- Introduction of antidote boxescontaining flumazenil and naloxoneto clinical areas for treatmentof therapeutic overdoses ofbenzodiazepines and opioids. Theboxes also contain a reporting formto encourage reporting as an adverseincident and to allow monitoring andencourage greater care in dosingparticularly during conscious sedation.- Introduced mandatory training oninjectable medicines for junior doctorsstarting work in the Trust.- Pharmacy implemented newprocesses (pink supply sheets andyellow bags) to ensure that urgentmedicines reach the patient to avoiddelayed and missed doses.- Actions taken to avoid unnecessaryomission of aspirin in patients at highrisk of blood clots and ensuring thatpatients take the doses as prescribedand given to them.- Implementation of a MedicationOmissions Audit.- A focused project commenced inthe first quarter of 2013 to improvemedication administration withspecific outcome goals of reducedmedication omission and betterpatient information. This work willcontinue through 2013/14.Reducing patient fallsPatient accidents form the largest groupof all patient safety incidents reportedto the National Patient Safety Agency(NPSA) via the National Reporting andLearning System (NRLS).The NPSA category “patient accidents”includes any slips, trips or falls bypatients. These may be non harm eventse.g. a patient has fallen walking along award corridor but not sustained an injury,or a harm event when a similar incidenthas occurred and the patient sustained abruise, cut or more serious injury.The Trust has invested heavily in stafftraining and equipment provision overthe past few years in order to reducethe number of patient falls. As previousnoted, quality and patient safety initiativesintroduced in year to reduce patient fallshave included:l Implementation of falls training as apart of clinical mandatory training andinductionl Production of e-learning and in-housefilms for falls prevention and fallsmanagementl Implementation of falls riskassessment documentationl Slippers provided to all patientsassessed at high risk of fallsl Walkrounds with dementia lead andestates established. Action plans inplace to improve environment forpatients at riskAnnual Report and Accounts 2012/13 75