Public Board of Directors papers 30 June 2022

1. Safe

1.4 – Learning - Patient Safety Incidents

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

Outcome

There is no automated upload of scans performed at the other trust to CWP as, whilst the scanner is part of the regional PET CT service, it has a different RBV number. The automated upload to CWP only occurs for scanners with an RBV of RBV01. The Clinical Oncologist and ST were not aware of this and so relied on results being drawn into CWP.

Delayed PET-CT results showed suboptimal coverage of disease site, however radiotherapy had already commenced

Clinicians will need to review PET Portal to check PET Scan reports for Trust 2 until alternative solutions can be investigated

W68210

Minor

1. Safe

Following procedural documentation. Education on validation Importance of validation and change control in other areas

W68343 Stem cells compromised during freezing process.

Failure to follow process

Minor

Need to reinforce monitoring of lying and standing blood pressures

W68464 Inpatient fall resulting in neck of femur fracture It is likely that an episode of AF caused the patient to fall/collapse

Moderate

The nurse-led protocol does not detail parameters for an urgent medical review in addition to the deferral process

Need for a clear monitoring and follow up process when patients are deferred

TBC

W68402 Communication failure regarding abnormal blood results

Telephone clinic process followed however misplacement of the outcome resulted in appointments not being schedules

Single point of failure identified within booking process and rectified

W68192 Delay in scheduling venesection treatment at The Christie Haematology @ Tameside

Minor

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