Public BoD papers 28.04.22

1. Safe

1.4 – Learning - Patient Safety Incidents

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

Outcome

Correct patient collected for theatre but the scrub team were expecting a different patient. Patient anaesthetised before identifying the correct patient.

Paper theatre lists are printed from theatreman, distributed and used to perform the WHO safer surgical checklist.

Importance of checking process – against master copy on theatreman

W66721

No Harm

1. Safe

The importance of a clearly documented escalation process for the assessment of issues related to the expiry of aseptically prepared products to ensure all relevant information is considered in the evaluation of whether to extend an expiry. The importance of assessing and documenting risk when there are changes to practices and processes

Communication failures leading to delay arising from a lack of documented processes/procedures relating to the escalation management of expiry issues and a lack of awareness of the arrangements for the pack allocation process

W66180 Aseptic product delivered beyond expiry time

No Harm

31

10