May 2012 - West Hertfordshire Hospitals NHS Trust

RiskIncident feedback and learningAll these incidents have been highlighted via the completion of our Online Datix Incident ReportingForm. This learning is being shared to help staff improve patient safety and carePoor communication between staff, patients and relatives. This is acommon theme in incidents, complaints and PALS and we must ensure thatcommunication is consistent, clear and effective and that patients andrelatives are involved. A lot of work is being carried out to enhancecommunication and patients are being included in handovers to ensurethat they are more aware as well as training being offered to staff.A number of incidents have been reported relating to medicationerrors including delayed admin, wrong dose, wrong time,prescription errors, delayed TTAs and omitted drugs. Please ensurethat errors are noted, reported, monitored and escalated and that you areadhering fully to the Medicines Management Policy and other relevantprotocols and guidelines.Patients admitted to hospital with Grade 3 and 4 pressure ulcersacquired in the community. These are reported to the PCT using theinformation reported on Datix. The PCT will then review the informationand decide the originating organisation who will be asked to declare andinvestigate the pressure ulcer as an SI as per usual process. Thus it isimportant that all questions relating to pressure ulcers on the Datix formare completed fully.A number of incidents have been reported to the Medicines andHealthcare products Regulatory Agency (MHRA) without notificationto the Clinical Engineering Department or completion of a Trustincident form. This was a Never Event and the investigation focussed oninterpretation and education amongst doctors in reading x-rays as well asadequate IT provision. In March 2011 a NG tube NPSA Alert(NPSA/2011/PSA002) stated that pH testing is used as the first line testmethod and X-ray is used only as a second line test.Patient Identifiable Data (PID). Please note that when completing theincident description on an incident form you should not include any patientdetails or other patient identifiable data. There are appropriate and specificfields on the incident form to enter such information. The Trust is monitoredby the NPSA on the number of incidents reported with personal identifiabledata so please ensure that you maintain patient confidentiality at all times.Incidents relating to mislabelling and / or unlabelled forms andspecimens have been highlighted. Please ensure that request forms andspecimens are labelled and correctly labelled in accordance with policies andprocedures and that such incidents are reported and monitored robustly toavoid any patient safety incidents.For more information contact the Risk Management and Governance Team on HH x2694 and WGH x7766, pooja.sharma@whht.nhs.ukStaff AwardsPatient Safety UpdateNew In-Patient PrescriptionGoing for Gold AwardsStaff Excellence Monthly AwardsDecember 2011Employee of the Month - Lynette Napper, Domestic, WatfordTeam of the Month - Maternity Department, WatfordJanuary 2012Employee of the Month - George Iddiols, Desktop Service Manager,Clinical Informatics, Hemel HempsteadTeam of the Month - Endoscopy Unit, Hemel HempsteadThe patientis mypriorityA ringingphone is myresponsibilityI smile,introducemyself andlistenI createa calmenvironmentI keeppatientsinformedTo nominate pleasecomplete a nominationform available via the Trustwebsite:www.westhertfordshirehospitals.nhs.uk orcontact the WorkforceDepartment on 01923217388 to request a form.For further details, please contact: Sharon Howarth(Lead Medicines Safety & Audit Pharmacist) Pharmacy Department,WGH x3319, sharon.howarth@whht.nhs.uk10May 2012