As part of the VTE risk assessment the target achievement level is 95%. The Trust has met this target each month this financial year.
Key Achievements
A number of measures are in place to ensure any non-compliance with completing the VTE risk assessments is quickly identified and acted upon;
Service Unit Managers and Service Unit Directors are notified on a weekly basis of
any areas that have been identified as non-compliant.
The completion of VTE risk assessments is incorporated into Service Unit Key
Performance Indicator dashboards.
Service Units are challenged on poor performance monthly to ensure robust plans
are in place to continue emphasising the need to have 100% compliance with completion of VTE risk assessments.
The Trust is currently trialling an electronic record system for capturing VTE data in Orthopaedics and early indications are that this system is being successfully implemented and VTE risk assessments appropriately completed.
Lessons Learned/Areas identified for further improvement
The Trust continues to strive to keep every patient free from harm and will endeavour to continue to make improvements. The roll out of the electronic record system identified above to other areas would assist the Trust in achieving this goal.
2.2.3 Theatres and Delivery Suite Ventilation
In October 2013, issues with the theatre and delivery suite systems came to light and experts who were called in confirmed that not all the ventilation systems met required standards. The ventilations systems are operated and maintained by the PFI company, which provides the building and services in which the Trust delivers care and treatment. We took immediate action, closing several of the theatres and diverting operations to ensure procedures only took place in those with the right environment.Remedial work, undertaken by the Trust’s PFI partners, has been externally verified as working to required standards. To ensure the air quality and air pressures within our theatres continue to meet requirements, we have introduced robust testing and monitoring
procedures. Throughout the process, exhaustive air quality tests have been carried out and there is no evidence that these issues have affected patients.
2.2.4 Serious Incidents Requiring Investigation
(SIRIs)
SIRIs are incidents that occur that have, or potentially may have, caused serious harm to patients or the Trust. Although measures are in place to prevent these incidents, when things do go wrong we ensure staff are open and honest about what has happened and encourage speedy reporting of such incidents. This allows for a culture of learning, which in turn will benefit patients by strengthening what we already do to ensure harm doesn’t come to patients whilst in our care.
SIRIs have to be reported immediately through the Quality and Safety Team, who then notify the relevant external organisations; a Root Cause Analysis (RCA) investigation is commenced. These investigations are led by a clinician or nurse and follow the incident trail to determine why the incident occurred and how it can be prevented in the future. In some instances a Non-Executive Director is involved in the investigation to give a ‘fresh eyes’ perspective on the investigations and to ask the questions that a health professional may not think to ask. Staff members are given training on how to complete these investigations
Before investigations are signed off as complete they are subject to rigorous review by Executive Directors to ensure necessary steps have been taken to identify the root cause and put in place mitigating actions to prevent incidents from reoccurring.
Speak Out Safely Campaign
This campaign was run in conjunction with the Nursing Times to encourage NHS organisations to develop cultures that are honest and transparent, and to actively encourage staff to raise the alarm when they see poor practice and to protect them when they do so.
As an organisation, we have signed up to the Speak Out Safely Campaign, making a public commitment to supporting staff who raise concerns. We have done this jointly with Herefordshire Clinical Commissioning Group.
Performance Data
Any types of incident could potentially be reported as a SIRI depending on the consequence; however there is national guidance available to ensure that the Trust reports accurately. The graph below shows all the types of incidents reported as SIRIs in 2013/14.
Top 5 Themes
The top 5 incidents reported as SIRIs are Category 3 pressure ulcer
Category 4 pressure ulcer
Patient fall resulting in a fracture or serious injury Drug incident
Never Events
Pressure ulcers are the most reported SIRIs and as such are a priority for the Trust. A significant amount of work has been undertaken by the Tissue Viability Team and nursing staff to reduce pressure ulcers as detailed in section 2.2.7.
Half of the pressure ulcers were reported by the Neighbourhood teams and the other half were reported by the acute and community hospitals.
Patient falls resulting in a fracture or serious injury is the next highest reported, with over half reported by the community hospitals. The actions taken to reduce the number of falls are detailed in section 2.2.14.
Key Achievements
Members of staff in the Maternity service can initiate a case review if they wish to discuss a patient’s care.
Development of a WHO Surgical Safety Checklist Policy.
Following a SIRI, a round table discussion is held with everyone involved in the incident to ensure a clear timeline is established.
Lessons learnt from serious incidents are shared Trust-wide through Trust Talk and Team Brief.