Work to establish a BNSSG wide protocol for the management of paediatric emergencies so that WAHT is part of a networked service which will include the new Southmead ED and BCH. Trust would be 4 5 16 Poor patient experience/outcome Divisions to be tasked with ensuring consultant representation Breach of CQC registration unaware of failures to on the D&T ARE committee through use of SPAs and job comply with Regulatory planning and Statutory Better collation between Datix reports/complaints in which requirements relating drugs and therapeutics are the major issue and the committee. to medicines Action required to identify the most frequent types of management and of medication errors and what can be done to reduce them. any resulting patient Strategy to guide the development of medicines optimisation is safety issues that arise. required. Metrics for monitoring the costs and quality of medicines used Cause: need to be established 1. An ineffective 6. Duty of candour needs to be developed in relation to harm medicines Governance arising from medicine (score changed from 12 to 9) structure 2. Lack of clinical representation from the divisions at the DTC 3. Failure to receive critical data relating to medicines incidents Failure to follow 4 4 16 Poor patient and family Establish regular training sessions in end of life care DMA CPR experience/outcome guidelines when issuing and DoLs as part of the medical induction programme and Breach of CQC registration a do not attempt CPR stat/man training programme for Consultants order (DNACPR) Cause: Lack of education and understanding relating to DNACPR orders Safeguarding Risk that 3 5 15 Poor patient experience/outcome In the short term find a way to shield or limit access to the Breach of CQC registration the identity of adopted system that meets the satisfaction of the adoption team in NS. children's new name In the mid term procure replacement Patient Admin and A&E and contact details systems and successfully implement by Mid 2015. (Trust Board could be revealed. This has approved an Outline Business case.) risk affects all
Work to establish a BNSSG wide protocol for the management of paediatric emergencies so that WAHT is part of a networked service which will include the new Southmead ED and BCH. Trust would be unaware of failures to comply with Regulatory and Statutory requirements relating to medicines management and of any resulting patient safety issues that arise. Cause: 1. An ineffective medicines Governance structure 2. Lack of clinical representation from the divisions at the DTC 3. Failure to receive critical data relating to medicines incidents 4 5 16 Poor patient experience/outcome Breach of CQC registration Divisions to be tasked with ensuring consultant representation on the D&T ARE committee through use of SPAs and job planning Better collation between Datix reports/complaints in which drugs and therapeutics are the major issue and the committee. Action required to identify the most frequent types of medication errors and what can be done to reduce them. Strategy to guide the development of medicines optimisation is required. Metrics for monitoring the costs and quality of medicines used need to be established 6. Duty of candour needs to be developed in relation to harm arising from medicine (score changed from 12 to 9) Failure to follow guidelines when issuing a do not attempt CPR order (DNACPR) Cause: Lack of education and understanding relating to DNACPR orders 4 4 16 Poor patient and family experience/outcome Breach of CQC registration Establish regular training sessions in end of life care DMA CPR and DoLs as part of the medical induction programme and stat/man training programme for Consultants Safeguarding Risk that the identity of adopted children's new name and contact details could be revealed. This risk affects all 3 5 15 Poor patient experience/outcome Breach of CQC registration In the short term find a way to shield or limit access to the system that meets the satisfaction of the adoption team in NS. In the mid term procure replacement Patient Admin and A&E systems and successfully implement by Mid 2015. (Trust Board has approved an Outline Business case.)