Public Board papers 31.03.22

1. Safe

1.4 – Learning - Patient Safety Incidents

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

Outcome

Due to complex anatomical reasons it would have been impossible to undertake a total or subtotal mastectomy of breast glandular tissue as it is likely that some covert breast tissue would be left behind. The letter was dictated under non-patient task and not linked to the patient. Local system controls were not possible as the secretary was not linked to view non- patient task correspondence for the clinical fellow.

W61226 Historical breast surgery

n/a report shared with MFT

No Harm

1. Safe

Urgent letter to expedite treatment was dictated but did not appear on EPRO (digital dictation) or Clinical Web Portal (CWP) and has led to significant delay in treatment for patient.

W65948 RCA Report TBC

The use of non-patient tasks in the system needs to be clarified and communicated with any and all entries checked against intended use at a local level.

Minor

Importance of untrained staff in moving and handling practice to be aware of initial action required when patients have fallen

W66528 Outpatient Fall

Accidental fall on the kerb outside of the hospital entrance

Major

The medication for three patients was placed in one bag to await delivery which led the taxi driver to believe that only three deliveries were required instead of five.

W66562 Medications of 3 patients delivered to home of a patient who took all medications given to him for over a week.

Medications for different patient must be kept in separate packaging

No harm

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