Quality report 2021-2022

was a different patient.

during telephone calls.

Concern that patient had been given incorrect medication dose.

The incident has been discussed with the staff involved in line with our Medicines Practice Operational Policy and highlighted to the rest of the team to ensure all staff are re-educated on the process for administering medication and signing the drug charts. In addition, the Medicine Chart has also been reviewed and re-drafted to make it clearer due to this discrepancy that led to this error. The team have since appointed two new members of staff and have also taken the opportunity to review their current processes and have introduced a new voicemail monitoring system and call return log. The Pharmacist has reflected on her practice to ensure due care and attention is taken when processing prescriptions. Team reminded of importance of ensuring all information is detailed on the request form when booking a procedure with the unit. Hotline staff to receive an update and overview of the SACT Outreach service for to ensure the correct advice is given going forward. Discussed error with the nurse involved and have re- educated them on this process to ensure all systems are checked in respect of the required medications. Complaint discussed with the nurse involved and re- educated her on this protocol to try and prevent this error from occurring again. System review to determine why patient is not being seen in the patient flow system.

Concern that patient cannot contact transport team.

Patient concerned that chemotherapy was not prescribed so she could not receive treatment when she attended the Trust. Patient concerned that there is conflicting information being given regarding her appointments and this is causing delays. Patient concerned that there are constantly delays with regard to her appointments. Patient concerned incorrect advice was given by the Hotline in relation to SACT Outreach Service. Patient concerned that they did not receive their medication prior to being discharged from the Trust. Patient concerned that the nurse preparing treatment mis-read the correct protocol.

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