AH ANNUAL REPORT 2018

• To complete and roll out the new electronic Root
Cause Analysis tool for all medication errors that
result in harm, which includes identification of harm,
contributory factors and financial implications.
• Implement a new independent checking process
across the trust.
• Reviewing Ulysses functionality to make it easier to
report an incident (e.g. more drop down functions).
• Making staff more aware of the Yellow Card scheme.
We are planning an open day forum around Yellow
Card reporting.
• Running a Medication Safety Week in June
2018 during which we will run medication safety
workshops.
A.I.M.S
(Alder Hey Improving
Medication Safety)
3.3.7 Reducing Harm from Pressure
Ulcers - Sign Up To Safety Pledge
Aim: No avoidable pressure ulcers.
Targets: From the 2014/15 baseline:
1. Reduce avoidable hospital acquired grade 2
pressure ulcers by 50%; this represents 10.
2. Reduce avoidable hospital acquired grade 3
pressure ulcers by 50%; this represents 1.
3. Achieve zero avoidable hospital acquired grade 4
pressure ulcers.
tubes which are reflective of national research showing
that most paediatric pressure ulcers are device related.
Alder Hey continues to have a strong focus on
education and training in the prevention, recognition
and treatment of pressure ulcers and clarifying and
simplifying reporting procedures.
Whilst the reported figures in the table below reflect
an increase in numbers of pressure ulcers reported,
these include all pressure ulcers, avoidable and
unavoidable. We have now introduced an improved
system of defining when Grade 3 and 4 pressure ulcers
are avoidable and are taking specific steps to address
these through undertaking Root Cause Analysis and
sharing lessons learned. The increase in numbers
is reflective of a greater awareness and improved
education across the Trust which has led to increased
reporting. All of the Grade 3 pressure ulcers are linked
to medical devices. Reducing the number of pressure
ulcers remains a high priority for the Trust and we
continue to take action through the Trust wide pressure
ulcer action plan, for example we are seeking to identify
a means of safe cushioning of cannula devices to avoid
pressure ulcers.
Grade 2 Grade 3 Grade 4 Total
2014/15 21 2 0 23
2015/16 23 1 1 25
2016/17 27 7 0 34
2017/18 32 6 0 38
Outcomes:
1. Increase of 11 grade 2 hospital acquired pressure
ulcers since 2014/15: this represents 32.
2. Increase of 4 hospital acquired grade 3 pressure
ulcers since 2014/15: this represents 6.
3. Achieved zero grade 4 hospital acquired pressure
ulcers.
4. Total number of pressure ulcers of grades 2-4 is
38 compared to 23 in 2014/15.
A pressure ulcer is an injury that breaks down the skin
and underlying tissue due to pressure, friction and
shear or a combination of these. They can be very
painful and debilitating and are often preventable. It is
recognised that immobilised and acutely ill neonates
and children are at risk of developing pressure ulcers,
particularly in a critical care environment. Most pressure
ulcers within our organisation are associated with
medical devices such as cannula and endo-tracheal
35
30
25
20
15
10
5
0
Number of Reported Hospital Acquired
Pressure Ulcers
Grade 2 Grade 3 Grade 4
2014/15
2015/16
2016/17
2017/18
Alder Hey Children’s NHS Foundation Trust 132
Annual Report & Accounts 2017/18