Public Board of Directors papers 241122

1. Safe

1.4 – Learning - Patient Safety Incidents

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

Outcome

Daily checklist implemented, each staff member in referrals and bookings record their own initials, the referral number, where it has been uploaded and any comments. Checklist initially will be peer reviewed, with aim to audit/peer review all actioned referrals in the future. Daily overbookings updates and monitoring email activity.

The complete referral process for registering new patients was not followed by the referrals and bookings team. This led to the patient not appearing on the consultants triage list within CareFlow and there was no open unappointed referral on the Access Pack

W71215 NWS

Missed referral of patient

Minor

1. Safe

Day porter undertaking a delivery of pharmacy fluid boxes to Ward 12 treatment room twisted their knee and required an ambulance to take them to A+E.

W71694 CEF

Highlighted need for equipment checks To implement services for portering wheeled trolleys

Lifting boxes into fluid store twisted knee

Moderate

W71793, W71794, W71945, W71867 CSSS

The current processes in place to coordinate this pathway are not sufficient to enable efficient tracking and prioritisation of these patients to provide a safe service

Penile Cancer Pathway / Surgical Cancellations

Efficiently use resources to maximise theatre sessions

No Harm

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