Public BoD papers 26.5.22

1. Safe

1.4 – Learning - Patient Safety Incidents

Agreed learning and revised severity outcome following executive reviews March 2022 Ref Description Root cause Learning

Outcome

Software bug/hardware failure. Lack of on-site support/skilled engineers to fault find/fix problem (had to wait for Manufacturer support). Laptop not configured for use on cart The patient sadly passed away from septicaemia from an infected port which is a recognised consented complication of this procedure.

One laptop had not been configured to be interchangeable between carts.

W67441 Radiotherapy equipment failed after patient was anaesthetised for procedure.

Moderate

1. Safe

A patient had a portacath inserted by The Christie early November 21. A few weeks later admitted to his local trust with a high temperature, the portacath was found to be infected.

W67756

Delay in reporting incident as known complication of port insertion

Death

The importance of ensuring all staff are aware of immediate action following an outpatient fall including location of specialist equipment Communicate the shared learning from this incident, ensuring that the ‘999’ functionality for rate input is only used in the small number of cases where this is required for larger volumes exceeding the pumps ‘safety net’ volume/time.

W67582 Outpatient fall in glass corridor.

Accidental fall whilst attending for a scan.

Moderate

The Hospira infusion pumps do not support certain volume/times to exclusively eliminate the requirement to use the ‘999’ override functionality which would support a safer pump programming practice. Rescheduling of face to face new patient consultation was not made due to miscommunication Patient went away from RTP scan with start date but no appointment time

W67781 Intravenous medication delivered to a patient too quickly.

Moderate

W67225 Patient missed radiotherapy appointments due to not being contacted.

Ensure to follow through with all relevant actions relating to changes

Moderate

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