Public Board of Directors papers 27.01.22

1. Safe

1.4 – Learning - Patient Safety Incidents

Agreed learning and revised severity outcome following executive reviews November 2021 Ref Description Root cause Learning

Outcome

The importance of having efficient systems in place to ensure there are good communication links within the team. Drainage bags should not be in situ when patients transferred to ward following procedure. Airtight dressing required if chest drain falls out

No robust system currently in place for the clinical team to request actions to be completed

W63851 4 month delay in booking a clinic appointment for a patient displaying disease progression.

Minor

1. Safe

This displacement of the drain was secondary to the patients’ chronic lung collapse, however it is likely to have caused the surgical emphysema.

W64466 A delay of two days to act on a patient’s chest drain catheter falling out.

Moderate

Known Complicati on Death

Patient receiving radiotherapy as an out patient returned home and later that evening suffered a cardiac arrest. A complex clinical pathway via MSCC pathway, patient did not receive treatment for cord compression and further complicated by patient developing COVID-19.

Symptoms were not suggestive of a cardiac event and therefore presenting symptoms were appropriately managed.

Development and dissemination of a red flags document for therapeutic radiographers including chest discomfort as a symptom requiring clinical review.

W64526

The importance of continuity of Clinical Oncology input – team based vs on-call – to aid communication with medical oncology team The importance of completing checking processes as per policy Communication of the correct process for escalation of care out of hours for patients under the care of TCPC

Delay to planned procedure due to contracting nosocomial infection (COVID-19)

W64768

TBC

Failure to follow policy at several steps throughout the transfusion process. The escalation process from CPP to TCPC was insufficient

W64776 Wrong blood component transfused

No Harm

W64807 Failure to act on low blood sugar from routine blood results.

Minor

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