Patient Safety Issues in Patient Safety Issues in GynaecologyGynaecology

Joanna Thomas & Louise Joanna Thomas & Louise SamworthSamworth

Saint Mary’s HospitalSaint Mary’s Hospital

ManchesterManchester

IntroductionIntroduction

• Active involvement in ongoing Active involvement in ongoing strategies to improve patient safetystrategies to improve patient safety

• Share experiencesShare experiences

• Highlight challengesHighlight challenges

• Future plans and developmentsFuture plans and developments

INCIDENTS REPORTED285

ACCESS, ADMISSION, TRANSFER, DISCHARGE

17 BLOOD TRANSFUSION

2

CLINICAL ASSESSMENT

9

CONSENTCOMMUNICATIONCONFIDENTIALITY

22

DOCUMENTATION32

FIRE1

INFECTIONCONTROL

4

INFRASTRUCTURE37

LABORATORYTEST

19

MEDICAL DEVICEEQUIPMENT

23

MEDICATIONERROR

17

PERSONAL ACCIDENT/INCIDENT

43

RESUS1

SECURITY3

SELF-HARMINGBEHAVIOUR

1

TREATMENT/ PROCEDURE

39VIOLENCE

DISCRIMINATION9

NOT STATED6

Medication Error - EpiduralsMedication Error - Epidurals

Problem IdentificationProblem Identification• Increase in epidural useIncrease in epidural use• Epidural key locationEpidural key location• Epidurals being stopped prematurelyEpidurals being stopped prematurely• Implementing Trust protocolImplementing Trust protocol• Inexperienced, junior staffInexperienced, junior staff• Ward staffing issuesWard staffing issues• Professional confidence & abilityProfessional confidence & ability

Medication Error - EpiduralsMedication Error - EpiduralsGenerating & Implementing SolutionsGenerating & Implementing Solutions

• Support from experienced acute pain nurse Support from experienced acute pain nurse and MDTand MDT

• Promotion link nurse systemPromotion link nurse system

• Epidural pump training sessionsEpidural pump training sessions

• One to ones with competency frameworkOne to ones with competency framework

• Key locationKey location

• Review skill mix & recruitment driveReview skill mix & recruitment drive

• Review induction & preceptorshipReview induction & preceptorship

• Monitor effectiveness & auditMonitor effectiveness & audit

Medical Devices & Medical Devices & EquipmentEquipment• Centralised equipment replacement Centralised equipment replacement

programmeprogramme• Numerous medical devices reaching Numerous medical devices reaching

end of serviceend of service• Implementing fair & consistent Implementing fair & consistent

approach to prioritising requirementsapproach to prioritising requirements• Introduction of risk assessment to Introduction of risk assessment to

support processes risk & support processes risk & equipment registersequipment registers

• Link with Health & Safety; Medical Link with Health & Safety; Medical Device Training programmesDevice Training programmes

Medical Device Replacement: Medical Device Replacement: Risk AssessmentRisk Assessment

RISK IDENTIFICATION AND ASSESSMENT Page 1 of 1 Area Gynae & Paed Theatres Risk

Assessor Sara Moore Date Dec 04 Date of

Review 2 monthly

Ref DESCRIPTION OF RISK – describe the RISK ASSESSMENT RISK potential problem. Severity Likelihood RATING

EXISTING CONTROLS – physical controls and/or systems currently in place to reduce the risk of adverse incidents? (S) (L) (SxL)

RISK RANK

Gyn 015

Risk of patient injury and DVT resulting from poor positioning during major laparoscopic and oncology procedures when traditional Lloyd Davies or lithotomy poles are used. Several incidents have been reported of lower limbs moving during surgery, which might have caused harm and injury.

Assessment and evaluation during positioning of patients in lithotomy position. Further assessments following procedure. Padding applied to current Lloyd Davies stirrups.

4 3 12 3rd Div

Senior Manager Validating Assessment Joanna Thomas Date Dec 04

ADDITIONAL CONTROLS REQUIRED – What action needs to be taken to eliminate or reduce the risk so far as is reasonably practicable?

SUBSEQUENT RISK RATING IF

ADDITIONAL CONTROLS ARE

INSTITUTED Ref S L (SxL)

COST (£)

PRIORITY PERSON RESPONSIBLE

TIME SCALE

PROGRESS

Purchase of inflation boots. 4 1 4 5,400 HIGH

THEATRE MANAGER

2 MTHS

RISK TREATMENT / ACTION PLANNING

Multidisciplinary team Multidisciplinary team functionsfunctions

Problem identificationProblem identification

• Availability of and access to doctorsAvailability of and access to doctors

• Prioritisation of case loadPrioritisation of case load

• Communication between Communication between professionalsprofessionals

• Organisational cultureOrganisational culture

• Consultant awareness and supportConsultant awareness and support

Multidisciplinary team Multidisciplinary team functionsfunctionsGenerating & Implementing solutionsGenerating & Implementing solutions

• Expanding nursing rolesExpanding nursing roles

• Ensuring evidence base to decision Ensuring evidence base to decision makingmaking

• Skills drillsSkills drills

• Consultant hot days Consultant hot days

• Ward rounds for emergency case Ward rounds for emergency case reviewsreviews

Promoting patient safety in Promoting patient safety in GynaecologyGynaecology

• Multifaceted approachMultifaceted approach• Continuous education programmesContinuous education programmes• Integration of clinical governance Integration of clinical governance

activityactivity• Link with individual performance & Link with individual performance &

professional development reviewsprofessional development reviews• Re-launch trigger factorsRe-launch trigger factors• Focus on Infection ControlFocus on Infection Control

Seven Steps to Patient Seven Steps to Patient SafetySafety• Build a safety cultureBuild a safety culture• Lead and support your staffLead and support your staff• Integrate your risk management Integrate your risk management

activityactivity• Promote reportingPromote reporting• Involve and communicate with patients Involve and communicate with patients

and the publicand the public• Learn and share safety lessonsLearn and share safety lessons• Implement solutions to prevent harmImplement solutions to prevent harm

NPSA (2004)NPSA (2004)

Joint RCOG/ENTER MEETING

Risk Management and Medico-Legal Issues In Women’s Health

25 to 26 April 2007