Public Board of Directors papers 260123

1. Safe

1.4 – Learning - Patient Safety Incidents

Agreed learning and revised severity outcome following executive reviews up to December 2022 Ref Description Root cause Learning

Outcome

• To speak to ward staff about the importance of checking all pages of the Kardex. • Disseminate information on tumourlysis syndrome on the learning bulletin or Friday focus. • Consider Christie Learning Zone as source of tumourlysis training • Tumourlysis training for Band 5 staff on unit • Junior doctor teaching session- to provide education on tumourlysis and

Patient receiving CHOP chemotherapy for treatment of lymphoma. Rasburicase medication was prescribed to reduce the potential effects of tumour lysis syndrome. When the patient was found to have tumour lysis syndrome it was noted the rasburicase had not been administered. The patient had a procedure performed on June 8th 2022 and was discharged on same day from IPU. No outpatient appointment was made, despite the operation note and discharge summary requesting a clinic appointment in 3-4 weeks. This was not realised until the patient called on 20th October 2022 to report a non healing wound

1. Safe

Minor

Failure to follow process

W73164

There was no process in place to ensure patients undergoing urology surgery received appropriate follow up appointments

W72981

New process established to ensure follow up appointments are made

No harm

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