Public Board of Directors papers 27-10-22

1. Safe

1.4 – Learning - Patient Safety Incidents

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

Outcome

Extravasation of chemotherapy due to venous fragility. In addition, the extravasation was not apparent until after the patient had been discharged which resulted some delay in the escalation and management of the extravasation.

To reiterate to staff the importance of informing patients of extravasation signs and symptoms.

Minor

W70783 An extravasation of chemotherapy

1. Safe

Escalate to Patient Information Committee to develop a process to standardise content for key issues in patient information leaflets related to treatment, and to incorporate learning from incidents. To be discussed at Friday focus. Information on microguides to be disseminated to clinical staff. Continuation of teaching session for junior doctors on complications of immunotherapy.

P tient developed hand injury following possible extravasation of chemotherapy

Major (not declared SI)

W70371 (SI)

Incidental infection following cannula insertion, complicated by immunosuppression.

A patient developed DKA due the management of their sliding scale insulin A positive microbiology result was not reviewed. The patient subsequently required admission for IV antibiotics

Policy was not followed when discontinuing the variable rate insulin infusion (VRII), though policy states to seek advice that would not have been available at that time.

Minor

W70909

TBC

TBC

No harm

W69740

TBC

TBC

Minor

W71283 Patient acquired diabetic ketoacidosis whilst in Hospital.

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