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					                                                                                                                                                      Appendix 1
                                         NBT Clinical Incidents Annual report – Edited Highlights


Chart 1 shows the correlation between numbers of incidents reported and incident rate per
1000 occupied bed days. It should be acknowledged that a high incident rate indicates a
healthy culture of reporting. The peaks in incident rate shown in Chart 2 are also a result of high
levels of non-inpatient activity.
                                                              Incident rate by Directorate

                           3500                                                                                           120
         No of incidents




                           3000                                                                                           100




                                                                                                                                Incident rate
                           2500                                                                                           80
                           2000
                                                                                                                          60
                           1500
                           1000                                                                                           40
                            500                                                                                           20
                              0                                                                                           0




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                                             No of incidents        Incident rate per 1000 occupied bed days
                                                                                                                                                 Chart 1


Chart 2 shows that 64.5 % all reported clinical incidents result from the top 10 causes.
Ensuring actions are taken to resolve these would potentially have a large impact on the
number of incidents reported. (The category “Others” represents the other 129 clinical risk
cause categories that are reported and recorded onto the Trust incident database. More
information about these can be obtained from the Clinical Risk Department if required).



                                                                    % of all incident types




                                                                                                Patient Falls
                                                                                                    26%
                                                      Other
                                                      31%




                                         Sample/test                                                  Medication Errors
                                            2%                                                             10%

                                   Delayed treatment
                                         2%                                                    Equipment
                                                                                                  7%
                                                                                       Pressure ulcers
                                   Breach of policy           Communication
                                                                                            6%
                                        3%                       failure
                                                                   4%
                                                  Documentation
                                                      4%                 Staffing
                                                                            5%                                                                  Chart 2
                                                                                                              Appendix 1
Impact of incidents.

All incidents reported are graded for impact/severity and likelihood/frequency. The severity grading is
reported to the National Patient Safety Agency. As the chart below shows, the vast majority of incidents
are insignificant or minor. However, it must be noted that to date only 70.3% of incidents reported have
had the accompanying Manager’s Report returned. Thus the Trust cannot be assured that the remaining
incidents have been appropriately investigated and actioned. The severity of incidents shows no marked
differences from the previous year, except an increase in near misses reported (8% in 2005/6, 16% this
year).

The Clinical Risk Department have sought to address some of the issues that may contribute to this
problem by working closely with some of the Directorates and this has seen a 10% improvement on last
year’s return rates.

                                              Impact of Clinical Incidents
                                                         4 Major            5 Catastrophic
                                                           0%                    0%
                                       3 Moderate
                                          2%


                                                                       Manager's Reports
                                         2 Minor                         not received
                                          13%                                30%




                                       1 Insignificant
                                            39%                       0 Near Miss
                                                                         16%




             Summary of actions underway to address Trust’s top 5 incident causes
Cause                     Actions taken/planned                             Further recommendations for Directorate
                                                                                                action
Patient    Falls Group meets quarterly                                    Ensure reviewed falls risk assessment tool
falls      Policy & accompanying risk assessment tools                     with care plan is available & in use
            developed.                                                     Promote use of safe manual handling
           Overlay mattresses replaced with mattress                       techniques at all times
            replacement systems                                            Check bed safety rails used in accordance
           Patient safety alert re bed rail usage                          with policy
           Falls Awareness day staff competition                          Consider requirement for staff awareness
           Compliance with policy audited & feedback reports               training
            with action plan circulated                                    Ensure Directorate gets feedback from Trust
           Effects of suitable seating project planned                     Falls Group meetings
           Trial of non-slip socks
           Some ward staff training delivered
           Manual handling induction training includes fallen
            patient scenario
           Trustwide review of bed safety rail management &
            policy under developed
           Restraint Policy under development
Medic      Audit piloted in medical directorate prior to Trustwide      To undertake mini Root Cause Analysis on
ation       implementation                                                drug errors with patient impact grade 2 and
errors     Policy CP5i updated                                           above, and implement appropriate actions
           Pharmacists interventions
           Missed dose audits
           Work on reconciliation of drugs as part of the SPI
                                                                                                                        2
                                                                                                               Appendix 1
            initiative
           Review of anti-coagulation risks in line with the SPI
            work and NPSA alert.
Equip      Policies in place                                           Ensure all clinical areas have an active clinical
ment       Clinical Equipment Group meet regularly                      equipment co-ordinator
           Featured on Trust Risk Register                             Ensure TNA updated regularly and staff
           Network of clinical equipment co-ordinators,                 training needs met
              green/orange card holders etc                             Ensure all loan equipment cleaned and
           Training needs analysis (TNA) proformas completed            returned to source as soon as no longer
              to show who has been trained                               needed, to maximise usage within Trust.
           Trustwide distribution of MHRA alerts                       Ensure risk assessments undertaken on critical
                                                                         items to ensure back-up systems are available
                                                                         in the event of failure.
                                                                        Ensure forward planning of budgets includes
                                                                         replacement of critical equipment as
                                                                         appropriate, and that unmet requirements are
                                                                         included in the directorate risk register.
Pressu     Huntleigh bed/mattress contract in place                    Ensure patients on dynamic mattresses are
re         Model of care in place to aid prioritisation of clinical       re-assessed frequently for their equipment
ulcers      need                                                           needs
           Pressure ulcer prevalence & incidence monitored             Ensure dynamic mattresses returned to
            monthly and fed back to clinical areas via Modern              library promptly to maximise usage within
            Matrons                                                        Trust
           Pressure ulcer prevention & management policy in            Ensure staff have received green card
            place (ratified March 2007)                                    training for bed & mattresses
           Green card training for profiling beds and dynamic
            mattresses available on both sites weekly
           Huntleigh Clinical Nurse Advisor available to support
            staff
           Link nurse system in place with regular meetings
           Training in pressure ulcer prevention & management
            available
           Pressure Area Care Support Nurse to commence
            post in September 2007
           Imminent purchase of additional mattress stock
Staffin    Off duty required 6 weeks in advance to enabling            Ensure off-duty written in a timely manner
g           pre-booking bank staff                                      Ensure appropriate levels of staff on leave
           Rostering rules agreed with Heads of Nursing &             (holiday, study leave etc) at any one time
            disseminated to all ward leaders                            Consider methods to ensure effect of frozen
           Contingency plans to reduce agency nursing                 jobs distributed across Directorate
            developed & implemented                                     Maintain recruitment to medical & surgical
           Guidelines for advance booking of temporary staff          pools
            reviewed June 06                                            Grow specialist nursing pools & develop
           Development of specialist nurse pools                      specialist bank staff in ITU, A&E, NICU, theatres
           Audits undertaken of unfilled shifts
           Review of maternity leave & annual leave
            arrangements




                                                                                                                       3
                                                                                                                                                      Appendix 1
Top 5 Causes of Clinical Incidents by Directorate
The charts that follow show the top 5 reported incident causes as a percentage of the total number of incidents
reported for each Directorate. The category “Others” represents the other 134 clinical risk cause categories that
are reported and recorded onto the Trust incident database. More information about these can be obtained from
the Clinical Risk Department if required.
                                                                                             Critical Care Directorate


                      Clinical Support Directorate

                                                                                                                          Equipment
                                                                                                                            21%


              All other incidents                    Medication errors
                     28%                                  27%
                                                                               Other incidents
                                                                                                                                  Pressure ulcers
                                                                                    49%
                                                                                                                                       10%



             Communication                                                                                                  Documentation
                 7%                                     Sample / test errors                                                    9%
                                                              12%
               Blood transfusion
                      7%                        Documentation
                            Test results            11%
                                8%                                                                                                          Communication
                                                                                                     Staffing shortages                        failure
                                                                                                             5%                                  6%




                            Medicine Directorate



                                                                                          Musculoskeletal Directorate
                    All other
                   incidents
                      24%

                                                                                            Others
 Absconded                                                Falls                              32%
    3%                                                    50%                                                                    Falls
                                                                                                                                 42%

 Staffing
shortages                                                                              Equipment
   7%                  Pressure                                                           5%

                        ulcers             Medication                                 Staffing                 Pressure ulcers
                                                                                        5%       Medication
                          7%                 errors                                                 7%
                                                                                                                    9%
                                              9%




                Neurosciences Directorate

                                                                               Renal and Transplant Directorate



                                               Falls                                                                  Falls
                          Others               29%                                           Others
                           37%                                                                                        26%
                                                                                              30%
              Communica          Medication
                 tion                                                                  Pressure
                                    15%
                              Equipment                                                                 Medication
                 6% Pressure                                                            ulcers
                                                                                      Communica
                       ulcers    7%                                                            Equipment 20%
                                                                                          6%
                                                                                         tion
                                    6%                                                           10%
                                                                                          8%




                                                                                                                                                              4
                                                                                                             Appendix 1

                                                          Women & Child Health Directorate

                 Surgical Directorate



                                                                                 Medication
                                                                                   17%

                                        Falls
                                        26%
                                                                                           Clinical
                                                                                          Equipment
         Other
                                                                                            10%
         41%
                                                          Other
                                                          52%
                                                                                          Breach of policy
                                                                                               8%
                                            Medication
                                              10%                                     Communication
                                                                                          8%
                                                                               Staffing
                                     Pressure ulcer
          Documentation                                                          5%
                          Staffing        9%
              6%
                            8%




            Learning Lessons – Recommendations for clinical Directorates

   Ensure that incidents are investigated immediately, or as soon after the events as possible.

   Feedback the outcome of the investigation to the staff who reported or were involved in the
    incident.

   Ensure this report and other incident reports discussed as an agenda item at all relevant
    Directorate and department meetings.

   Ensure that uncontrolled risks reported via AIMS are entered onto local risk register and
    actions planned and escalated as necessary.

   Ensure departments develop an action plan to address issues highlighted in this report.

   Ensure progress with action plans is monitored within the Directorate, and completed action
    plans submitted as evidence for Standards for Better Health and NHS LA Risk Management
    Standards (formerly CNST) assessment.

   Consider using the RCA process for an in-depth investigation of commonly occurring
    incidents to enable robust actions to be planned.




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