Leadership Royal College Emergency Complaints and development Medicine Review of incidents involving Emergency Care Services discharge processes Sept 2014 Medication incidents DoLS register Secretarial support to surgeons. Theatre scheduling. Stat mand training compliance Staff access to policies via the intranet. Failure to ensure Lead Director Internal Trust scored 97 Control gaps Lead 4 4 16 Pharmacist AO for Controlled D&TC minutes out of possible Homecare policy medicines are review for safely and drugs MMOG minutes 144 on TDA contract review and Medical securely Lead Pharmacist Quarterly Controlled Drug medicines governance process. Director Drugs & Therapeutic Audits optimisation Patient Group procured, prescribed, Committee meets bi Reporting to Q&GC assessment Direction (PGD), dispensed, monthly External undertaken in unlicensed Medicines Quarterly report to CD Sept 14 medicines and Self prepared, – administered Management Local Intelligence Network. improvement. Medication Policies and monitored Operational Group TDA medicine optimisation Ward Q2 CD for approval in Mar in accordance meets monthly assessment audit shows 2015. Quarterly controlled Medication Safety compliance at No central register of with the statutory drug audit and 6 Thermometer 92% and above PGDs. requirements of monthly secure NHS Protect medicines for all Number of expired handling audits security self assessment requirements PGDs. the Medicines Act 1968 and undertaken and tool. apart from CD No plans for the Health and reported to Medicines order book locked electronic Management away signing for prescribing. Social Care Act 2008. Operational Group. receipt of CD Lack of ward / dept A bi-monthly report orders- improving. medicines provided to the Quality June 2014 management SOPs Safe Domain internal CQC and training.
Leadership development Royal College Emergency Medicine Review of Emergency Care Services Sept 2014 DoLS register Complaints and incidents involving discharge processes Medication incidents Secretarial support to surgeons. Theatre scheduling. Stat mand training compliance Staff access to policies via the intranet. Failure to ensure medicines are safely and securely procured, prescribed, dispensed, prepared, administered and monitored in accordance with the statutory requirements of the Medicines Act 1968 and the Health and Social Care Act 2008. Safe Domain Lead Director AO for Controlled drugs Lead Pharmacist Drugs & Therapeutic Committee meets bi monthly Medicines Management Operational Group meets monthly Quarterly controlled drug audit and 6 monthly secure handling audits undertaken and reported to Medicines Management Operational Group. A bi-monthly report provided to the Quality Internal D&TC minutes MMOG minutes Quarterly Controlled Drug Audits Reporting to Q&GC External Quarterly report to CD Local Intelligence Network. TDA medicine optimisation assessment Medication Safety Thermometer NHS Protect medicines security self assessment tool. Trust scored 97 out of possible 144 on TDA medicines optimisation assessment undertaken in Sept 14 – improvement. Ward Q2 CD audit shows compliance at 92% and above for all requirements apart from CD order book locked away signing for receipt of CD orders- improving. June 2014 internal CQC Control gaps Homecare policy contract review and governance process. Patient Group Direction (PGD), unlicensed medicines and Self Medication Policies for approval in Mar 2015. No central register of PGDs. Number of expired PGDs. No plans for electronic prescribing. Lack of ward / dept medicines management SOPs and training. Lead Pharmacist review for Medical Director 4 4 16