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					                                                                                                                                        Royal Devon Exeter NHS Foundation Trust
                                                                                                                                        - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                       Treatment Plan
                                Source of Risk




                                                                                                                                                                                                                                                                                                   Responsibility
         Department or




                                                                                                                                                                              Consequence




                                                                                                                                                                                              Level of Risk




                                                                                                                                                                                                                                       Action / Risk
                                                                                                                        Measures in
                                                                      Description




                                                                                                                                                                                                                                                                                review date




                                                                                                                                                                                                                                                                                                                      Date on the
                                                                                                                                                                                                                                                                                Timescale /
                                                                                                                                                                                                              Risk Score
                                                                                                                                                            Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                    Cost (£)




                                                                                                                                                                                                                                                                                                                      register
                                                                                                                        Control

                                                                                                                        place
                                                                      Risk
                                                                                                                                                                                                                 WEEU has successfully bid to increase the
                                                                                                                                                                                                                 medical establisment by a 7th Consultant and a
                                          Ophthalmic OPD follow-up delay, which varies All medical and practitioner staff are aware of                                                                           staff grade, and has an outstanding proposal for                             Directorate
    Specialist           Directorate Risk between consultant from 3 months to 9          the problem. The Eye unit has raised this with                                                                          a mobile clinic which will increase follow-up                                Manager -
125 Surgery              Register         months.                                        the PCT with a proposal to address the issue.    Likely (4)                      Major (4)          High             16 capacity by 5,000.                                  0         Ongoing         Surgery              1/23/2007
                                                                                         Contingencies are to recruit LATs or recruit to
                                          Failure of Junior Drs recruitment process with Trust doctor posts, or if necessary,                                                                                     WTD steering group has been set up which HR
                                          positions remaining unfilledthus Rotas may not Consultants to act down (policy). S Booth                                                                                are represented on. Looking at the use of other                             Director of
                                          be filled, patient saftey compromised, breach being appointed to control work required to                                                                               roles to alleviate some of the work. Meeting                                 Human
157 Trustwide            Risk Assessment of EWTD legislation.                            meet legislation                                Likely (4)                       Major (4)          High              16 bectween LL,EH, VP and MNO to take place.          0         Ongoing        Resources             6/3/2009
                                                                                                                                                                                                                  Implement reporting through ESR, roll out use
                                                                                                                                                                                                                  of ESR through managers and staff. Confirm
                                                                                                   Corporate induction day, local induction policy,                                                               essential training requirements and
                                         Essential training - inability to meet training           L&D facilitation of mandatory requirements.                                                                    communciate to staff with details of L&D
                                         requirements for key standards - potential                Recording of training using ESR. TNA available                                                                 offerings. Develop managers skills and
                                         reduction in 'health check' rating / non                  on Comex of all essentail training. Medical                                                                    knowledge in this area. Investigate other modes
                                         compliance with national standards (standard              device and training policy in place. Local                                                                     of delivery for essentail learning. Medical                                 Director of
                                         for better health and CNST). Compliancewith               induction sign off required as per Trust                                                                       device committee currently reviewing guidance                                Human
158 Trustwide            Risk Assessment medical device training and recording.                    induction policy                                 Likely (4)            Major (4)          High             16 to clinical areas.                                  0         Ongoing        Resources             6/3/2009

                                                                                                   An infection control management structure that
                                                                                                   is compliant with the Hygiene Code. Directors
                                                                                                   of Infection Prevention and Control designated
                                                                                                   to lead infection control team (ICT) and provide
                                                                                                   expert advice to the Trust Board. Infection
                                                                                                   control committee which supports the ICT and
                                                                                                   approves the annual programme of work.
                                                                                                   Evidence based policies and guidelines
                                                                                                   available in hard copy and via Comex.
                                                                                                   Infection control training provided for all staff as
                                                                                                   part of Corporate and Junior Doctor induction.
                                                                                                   Programme of ongoing education available for
                                                                                                   all clinical disciplines. Annual training updates
                                                                                                   for support staff. Use of alternatives methods
                                                                                                   to communicate new information i.e. news
                                                                                                   letter, email cascade. Link nurse scheme with
                                                                                                   training and forum meetings. Compliance with
                                                                                                   mandatory           surveillance      programme.
                                                                                                   Participation     in    a    mandatory national
                                                                                                   surveillance schemes for MRSA and GRE                                                                                                                                                       Director of
                                                                                                   bacteraemia, C.difficile in over 65's and                                                                                                                                                    Infection
   Infection                                     To minimise the risk to patients of acquiring a   surgical site infection with feedback to Almost                                                                                                                                            Prevention &
94 Control               National Target         healthcare associated infection                   clinicians.                                          certain (5)      Moderate (3)       Medium            15 Review compliance with revised Hygiene Code         0         On-going          Control




                                                                                                                                                                                                                                                                                                                                    1
                                                                                                                                       Royal Devon Exeter NHS Foundation Trust
                                                                                                                                       - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                   Treatment Plan
                                Source of Risk




                                                                                                                                                                                                                                                                                                Responsibility
         Department or




                                                                                                                                                                            Consequence




                                                                                                                                                                                            Level of Risk




                                                                                                                                                                                                                                   Action / Risk
                                                                                                                       Measures in
                                                                      Description




                                                                                                                                                                                                                                                                             review date




                                                                                                                                                                                                                                                                                                                   Date on the
                                                                                                                                                                                                                                                                             Timescale /
                                                                                                                                                                                                            Risk Score
                                                                                                                                                          Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                 Cost (£)




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                                                                                                                       Control

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                                                                      Risk
                                                                                                   Alert organism surveillance using an infection
                                                                                                   control software programme with specific
                                                                                                   feedback by directorate on ward acquired
                                                                                                   MRSA colonisation/infection and Clostridium
                                                                                                   difficile infection. In-house all organism
                                                                                                   bacteraemia surveillance with specialty specific
                                                                                                   feedback. Provision of patient information
                                                                                                   about MRSA, Clostridium difficile, vancomycin
                                                                                                   resistant enterococci, viral gastroenteritis.
                                                                                                   Audit of clinical practice with feedback to
                                                                                                   clinicians. Close liaison between the Infection
                                                                                                   Control Team, Matrons and Hotel Service
                                                                                                   Manager regarding environmental issues.
                                                                                                   Trust wide rollout of the NPSA hand hygiene
                                                                                                   campaign which includes: near patient alcohol
                                                                                                   hand rubs, posters, positive role modelling,
                                                                                                   patient involvement and observation audit with
                                                                                                   feedback to wards/dept. Provision of –ve
                                                                                                   pressure isolation rooms for airborne infection.
                                                                                                   Provision of some single room accommodation
                                                                                                   in each ward for isolation of infectious patients.
                                                                                                   Provision of admission rooms for patients with                                                                                                                                           Director of
                                                                                                   symptoms of viral gastroenteritis. Establish                                                                                                                                              Infection
   Infection                                     To minimise the risk to patients of acquiring a   steering group for implementing Saving Lives Almost                                                                                                                                     Prevention &
94 Control               National Target         healthcare associated infection                   delivery programme.                                certain (5)      Moderate (3)       Medium            15 Review compliance with revised Hygiene Code        0         On-going          Control
                                                                                                                                                                                                               A CAP 1 application has been submitted to
                                                                                                                                                                                                               purchase additional nasoendoscopes to enable
                                                                                                                                                                                                               all scopes to be washed and disinfected in the
                                                                                                                                                                                                               new Trust Central Endoscope washer
                                                                                                                                                                                                               disinfector as per guidelines; this would mean
                                                                                                                                                                                                               compliance with national guidance and
                                                                                                                                                                                                               Healthcare Standard C4c, and therefore the risk
                                                                                                                                                                                                               level would drop. Due to the cost of the naso-
                                                                                                   Current control measures are deemed                                                                         endoscope purcahse the order needed to go
                                                                                                   reasonable by infection control in the absence                                                              out to European Tender, this will delay the
                                                                                                   of a centralised decontamination facility.                                                                  introdction. However there is slippage in the
                                                                                                   Nasoendoscopes do not have a lumen                                                                          introduction of the Central Washer in
                                                                                                   therefore making them easier to clean than                                                                  Endoscopy and therefore teh pruchase may
                                                                                                   some        other      endoscopy      equipment.                                                            conincide with the opening of the new Central
                                                                                                   Instruments are washed manually then placed                                                                 Washer for scopes. Nicky Lavender will liaise
                                                                                                   in a steriliser solution for 5 minutes. However                                                             with procurement to ascertan possible delivery
                                                                                                   once the Trust introduces a centralised facility,                                                           dates and will update action plan as required.
                                                                                                   continuing to use local decontamination                                                                     11/9/08 the scopes have a arrived but due to
                                                                                                   methods will contravene national guidance (as                                                               lack of both washing and storage capacity in the
                                                                                                   set out above). It is the risk associated with                                                              central facility, and BC1 was developed to
                                                                                                   contravening this guidance that is being                                                                    purchase a dryer / storage cupborad for ENT
                                                                                                   assessed here (ie the likelihood of                                                                         OPD. This has been approved and in the
                                                                                                   contravening the guidance is certain; whereas                                                               procurement ordering process with an estimated                              Directorate
    Specialist                                   To ensure the Trust is compliant with             the actual risk of cross-infection is rare or Almost                                                        date of arrival within 2 months.                                            Manager -
128 Surgery              National Target         decontamination and cleaning guidelines.          unlikely).                                        certain (5)       Moderate (3)       Medium            15 24/3/09 - The Drying cupboard will be delivered 350 000      Ongoing         surgery              5/15/2007




                                                                                                                                                                                                                                                                                                                                 2
                                                                                                                                    Royal Devon Exeter NHS Foundation Trust
                                                                                                                                    - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                       Treatment Plan
                                Source of Risk




                                                                                                                                                                                                                                                                                                   Responsibility
         Department or




                                                                                                                                                                     Consequence




                                                                                                                                                                                     Level of Risk




                                                                                                                                                                                                                                       Action / Risk
                                                                                                                     Measures in
                                                                      Description




                                                                                                                                                                                                                                                                                 review date




                                                                                                                                                                                                                                                                                                                    Date on the
                                                                                                                                                                                                                                                                                 Timescale /
                                                                                                                                                                                                     Risk Score
                                                                                                                                                     Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                     Cost (£)




                                                                                                                                                                                                                                                                                                                    register
                                                                                                                     Control

                                                                                                                     place
                                                                      Risk
                                                                                                                                                                                                                  The Trust IMT Strategy sets out a five year IMT
                                                                                                                                                                                                                  strategic direction taking into account the
                                                                                                                                                                                                                  support of the Corporate strategic objectives.
                                                                                                                                                                                                                  The Trust will continue to engage with the NPfIT
                                                                                                                                                                                                                  but continue to develop and implement IMT to
                                                                                                                                                                                                                  support business and clinical requirements and
                                                                                                                                                                                                                  will review its position around NPfIT in two to
                                                                                                                                                                                                                  three years time. Business continuity strategies
                                                                                                                                                                                                                  recognize a limited requirement for clinical and
                                                                                                                                                                                                                  business systems in advance of CfH/NPfIT to
                                                                                                                                                                                                                  be managed through the Finance and IM&T
                                                                                                                                                                                                                  directorate and the Local Programme for IT
                                                                                                                                                                                                                  Board and IMT Shared Services Boards
                                                                                                                                                                                                                  respectively

                                                                                                                                                                                                                  To continue and, if possible, enhance the
                                                                                                                                                                                                                  programme of investing in management and
                                                 Support and Maintenance of IT Infrastructure                                                                                                                     information systems primarily aimed at
                                                 (Computer Networks and Systems) to continue       Annual Technology Refresh agreed through                                                                       enhancing patient care.
                                                 to meet the business needs of the Trust.          capital programme to ensure continued
                                                 Major Loss of Hospital Computer Network           compliance with CfH requirements and                                                                 Ongoing review of infrastructure re.
                                                 affecting a Key Clinical System (e.g. PAS,        businesss continuity. Information Governance                                                         performance and reliability with ongoing
                                                 Plato, Pathology, Radiology, A&E, …) or           Committee and PIMTEG, Connecting for                                                                 improvement plans. 2008/09 technology refresh
                                                 Business System (e.g. Finance Systems,            Health, Existing System Supplier Forum to                                                            programme planned to include PCs, server                                                Deputy
                                                 Purchasing Systems) resulting in systems          ensure ongoing compliance with DSCNs and       Possible                                              replacements and network upgrade at                                                    Director of
98 IM&T                  National Target         being unavailable for more than one day.          NHS spine compliance                             (3)           Major (4)        Medium            12 Heavitree.                                                   TBA        On-going          IM&T
                                                 The Implementation locally of connecting for
                                                 Health (National Programme for IT) across the
                                                 Exeter District community which includes a
                                                 number of discreet projects: Choose and Book,
                                                 Picture Archiving Communication System
                                                 (PACS) and Care Records Service. Failure to
                                                 meet corporate targets which are essential to
                                                 running the Trust successfully. Dependent
                                                 upon resillience of the NHS spine and centrally
                                                 hosted applications and servers with little
                                                 influence from local Trust perspective. CAB
                                                 and PACS implemented, however, centrally
                                                 hosted systems do fail from time to time, any
                                                 upgrades to systems take the systems down
                                                 for a whole weekend. With the Southern
                                                 Cluster LSP withdrawing from the national
                                                 contract, the contract is being renegotiated
                                                 with the remaining LSPs for the Care Record
                                                 Care Records Service system. The RDE IMT
                                                 Strategy (June 08) sets out its 5 years plan
                                                 prioritising its IMT investment to support the
                                                 Trust Corporate strategic objectives. EDS
                                                 contract extended until December 201 due to
                                                 EDS repositioning themselves as a software
                                                 supplier and system integrator due to Souther                                                                                                                                                                                                  Deputy
                                                 Cluster LSP withdrawl, However, pathology                                                        Possible                                              Programme managed with appropriate                                                     Director of
96 IM&T                  National Target         replacement system due to go live Spring 2009     Capital Control Group and Trust Board            (3)           Major (4)        Medium            12 programme documentation                                      TBA        Ongoing           IM&T




                                                                                                                                                                                                                                                                                                                                  3
                                                                                                                                           Royal Devon Exeter NHS Foundation Trust
                                                                                                                                           - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                            Treatment Plan
                                 Source of Risk




                                                                                                                                                                                                                                                                                                           Responsibility
         Department or




                                                                                                                                                                                  Consequence




                                                                                                                                                                                                  Level of Risk




                                                                                                                                                                                                                                            Action / Risk
                                                                                                                           Measures in
                                                                        Description




                                                                                                                                                                                                                                                                                        review date




                                                                                                                                                                                                                                                                                                                              Date on the
                                                                                                                                                                                                                                                                                        Timescale /
                                                                                                                                                                                                                  Risk Score
                                                                                                                                                                Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                            Cost (£)




                                                                                                                                                                                                                                                                                                                              register
                                                                                                                           Control

                                                                                                                           place
                                                                        Risk
                                                                                                      Provision of guidelines for management of
                                                                                                      C.difficile toxin positive pts including antibiotic
                                                                                                      treatment and hand washing. Surveillance of
                                                                                                      C.difficile infection fed back to Governance
                                                                                                      Committee and Infection Control Committee
                                                                                                      every quarter. Feedback to ward and
                                                                                                      directorate level of surveillance data in SPC
                                                                                                      chart format. Typing of samples by reference
                                                                                                      laboratory if clusters occur Designated
                                                                                                      isolation facilities in medicine for patients with
                                                                                                      laboratory confirmed C.difficile toxin positive.
                                                                                                      Number and placement of new cases reviewed
                                                                                                      at daily bed capacity meeting. Daily review of
                                                                                                      patients by ICT ( Mon-Fri) Provision of
                                                                                                      antibiotic prescribing guidance cards for
                                                                                                      medical staff. Inclusion of the importance of
                                                                                                      prudent antibiotic prescribing in infection
                                                                                                      control doctors induction and up date training.
                                                                                                      Review of environmental cleaning practices,
                                                                                                      including seeking advice of recognised national
                                                                                                      experts. Enhanced terminal cleaning of bed                                                                     Continue to provide a designated cohort facility                                  Director of
                                                                                                      spaces when C.difficile suspected. Commode                                                                     for medical patients with c.difficile infection.                                   Infection
                                                  Increased morbidity and mortality associated        cleaning protocols. Improved sluice storage                                                                    Continue to encourage prudent antibiotic                                         Prevention &
109 Trustwide            National Target          with Clostridium difficile 027 infection            facilities.                                            Likely (4)      Moderate (3)       Medium            12 prescribing.                                            0         Ongoing           Control   10/12/2007
                                                  Unreliable data held in the Electronic Staff
                                                  Record HR and Payroll system. Possible              Governance and Staff Infrastructure                                                                                                                                                             Director of
                         Directorate Risk         failure of integrity of reporting and accuracy of   established to support the implementation of           Possible                                                Data cleansing and interrogation exercise to be                                   Human
121 HR                   Register                 information.                                        ESR.                                                     (3)            Major (4)         Medium            12 undertaken on various parts of the system.              0         Ongoing        Resources             6/3/2009

                                                                                                                                                                                                                     Continue with proactive record management
                                                                                                                                                                                                                     strategies. Electronic Document Management
                                                  Health Record casenotes - very bulky, difficult                                                                                                                    system feasibility study started in July to look at
                                                  to retrieve and assimilate information causing                                                                                                                     viability of implementing EDM as a real time
                                                  potential clinical risk, financial risk as                                                                                                                         solution to replace the physical health record. If
                                                  consequence of potential clinical risk and                                                                                                                         agreement to proceed with concept of EDM, full                                     Deputy
                                                  increasing cost of storage and health and           Information Governance Committee; Clinical             Possible                                                business case will be produced by end of                                          Director of
145 Trustwide            Local Contract           safety risk to all users.                           Notes Issue Group, Trust Board                           (3)            Major (4)         Medium            12 financial year 2008/09                                TBA         on going           IM&T              9/18/2008

                                            Protection of children at risk from abuse, and
                                            communication. From the 1st April 2008, use
                                            of the Child Protection Register (CPR) was
                                            ceased nationally, and replaced with Child
                                            Protection Plans (CPP). The RD&E had
                                            previously held a copy of the CPR, updated
                                            monthly. Children presenting in Emergency
                                            Department were checked against the CPR.
                                            ED Staff now only contact social services
                                            (CYPS) if they have concerns about a child but
                                            will not be able to participate in the multi-             Discussions are being held with the                                                                            A business plan has been submitted to Devon
                                            agency protection plan and might not forward              safeguarding children designated doctor and                                                                    PCT for a designated paediatric liaison post.                                     Director of
                                            information which is crucial to a child's welfare         Devon CYPS so that a list of children subject          Possible                                                Awaiting for further advice from LSCB on the                                      Nursing &
144 Trustwide            Risk Assessment but as an isolated incident seems insignificant.             to a CP plan is sent to ED                               (3)           Moderate (4)       Medium            12 holding of a list of Child protection plans.          47000       On-going       Patient Care          9/2/2008
                                            Fire risk due to hot bulb over beds coming into           Safety bulletin circulated. Light guards being                                                                                                                                                    Head of
148 Trustwide            Incident reporting contact with bedding.                                     fitted.                                               Possible (3)      Major (4)         Medium            12 Ensure that lamps have guards on them                 4000         Jun-09          Estates             2/12/2009




                                                                                                                                                                                                                                                                                                                                            4
                                                                                                                                       Royal Devon Exeter NHS Foundation Trust
                                                                                                                                       - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                   Treatment Plan
                                 Source of Risk




                                                                                                                                                                                                                                                                                                   Responsibility
         Department or




                                                                                                                                                                         Consequence




                                                                                                                                                                                         Level of Risk




                                                                                                                                                                                                                                   Action / Risk
                                                                                                                      Measures in
                                                                      Description




                                                                                                                                                                                                                                                                                review date




                                                                                                                                                                                                                                                                                                                      Date on the
                                                                                                                                                                                                                                                                                Timescale /
                                                                                                                                                                                                         Risk Score
                                                                                                                                                         Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                  Cost (£)




                                                                                                                                                                                                                                                                                                                      register
                                                                                                                      Control

                                                                                                                      place
                                                                      Risk
    NNU,
    Paeds,                                        Unvaccinated staff have ability to transmit    Vaccination programme for new starters joining
    Maternity +                                   MMR infection to vunerable groups.             RDE Trust. Several catch up MMR vaccination                                                                Review Policy. Increase MMR protection levels                                  Director of
    othe rhigh                                    Unvaccinated staff may acquire MMR infection   programmes for identified high risk areas e.g.       Possible                                              by improving compliance with policy by                              Six -nine    Human
155 risk areas Risk Assessment                    themselves and require time off from work.     NNU, Paeds, Maternity etc.                             (3)           Major (4)        Medium            12 vaccination and/or serology screening.               20000          months     Resources                3/3/2009
                                                                                                                                                                                                                                                                              Long Term:
                                                                                                                                                                                                                                                                              Dependant
                                                                                                                                                                                                                                                                                   of IT
                                                                                                                                                                                                                                                                             development
                                                                                                                                                                                                                                                                                 locally.
                                                                                                                                                                                                            Improve completeness of result return and filing.                 Short Term:
                                                                                                                                                                                                            Long Term: Implementation of the EPR with                         As soon as
                                                                                           All request forms have clearly identified fields                                                                 electronic test requesting with compulsory data                    possible if
                                                                                           for entry of necessary demographics for                                                                          field entry. Short Term: Acqusition of Order                         agreed
                                         Appreciation of important pathology results       accurate return of results to where they are                                                                     Comms electronic requesting with mandatory                       reasonable/n
                                         may be delayed or missed because the              needed. Some results may be alternatively                                                                        field completion., project scheduled by Sept                       ecessary
                                         locations and/or Consultant identities for report accessed electronically via ward, etc terminals.                                                                 2010.Additional staff employment (Band 2) to                     compensator
                                         deliveries are not being included on request      However, there is no current mechanism for                                                                       troubleshoot for these forms/results in the                          y extra    Divisional
                                         forms such that they are not being included in ascertainment of whether this is actually                     Possible                                              absence of readily identifiable mechanism to                        revenue    Manager -
21 Trustwide             Risk Assessment the patient notes.                                occurring.                                                   (3)           Major (4)        Medium            12 improve form completion standards.                   13000            spend    Diagnostics              6/3/2009

                                                                                                 Recent MHRA inspection process, including
                                                                                                 site visit 12.12.09 did not identify any critical
                                                                                                 failures. Rigorous action plan put in place to                                                              Continue to work through and obtain MHRA
                                                  Failure to satisfy MHRA Inspection             address other noted deficiencies. Blood                                                                     sign off of current post inspection Action Plan.                                 Dirvisoonal
                         External                 requirements leading to closure of Blood       Transfusion Dept has rigorous quality                                                                       Further extension of quality assurance system                                    Manager -
156 Pathology            assessment               Transfusion Dept.                              management system in place to reduce risk.          Possible (3)     Major (4)        Medium             12 within Blood Transfusion Dept.                      TBD           Ongoing        Pathology             5/8/2009
                                                                                                 Actively planning within the Trust and with                                                                 National work is escalating. Trust is involved in
                                                                                                 partners and the Peninsula to manage an                                                                     working with local groups.flu pandemic plan                                        Chief
                                         The Trust will have difficulty coping with the          outbreak. This planning covers clinical,                                                                    tested internally and externally in November.                                     Operating
104 Trustwide            Risk Assessment effects of a Flu pandemic.                              operational communication systems.                  Unlikely (2) Catastrophic (5)      Low              10 Action plan being developed.                           0           Ongoing          Officer             2/23/2006

                                                                                     Legionella Control Team who review control                                                                             Board aware. Risks monitored. Continue with
                                                                                     arrangements. Legionella control policy and                                                                            control measures and exiting management
                                         Risk to staff, patients and contractors of  maintenance measures which reflect HSC                                                                                 regime. Consider installation of further water                                      Head of
100 Trustwide            Risk Assessment Legionella from the water systems           Approved code of practice and guidance (L8). Unlikely (2) Catastrophic (5)                         Low              10 treatment regimes.                                   £120K         Ongoing          Estates             1/23/2006
                                                                                     Guidelines (a working draft) for management of
                                                                                     Avian Influenza have been prepared and
                                                                                     distributed throughout the Trust. Guidelines
                                                                                     identify the need to use the HPA algorithm for
                                                                                     assessing pts who have returned from
                                                                                     countries with cases of Avian Influenza. The
                                                                                     guidelines also identify where such patients
                                                                                     should be accommodated within the Trust.
                                                                                     Personal Protective Equipment required in the
                                                                                     event of a case of Avian Flu has been made
                                                                                     available in EMU and ED. Procurement Dept
                                                                                     are aware of the details for reordering
                                                                                     additional PPE. Fit testing kits are available                                                                                                                                                            Director of
                                         Risk of cross-infection if an individual    within the Trust which the Infection Control                                                                                                                                                               Infection
                                         presented in EMU or ED with suspected Avian team will use to ensure that protective masks                                                                                                                                                            Prevention &
107 Trustwide            Risk Assessment Influenza                                   are worn correctly.                            Unlikely (2) Catastrophic (5)                       Low              10 Review guidelines                                      0           Ongoing           Control            3/16/2006




                                                                                                                                                                                                                                                                                                                                    5
                                                                                                                                  Royal Devon Exeter NHS Foundation Trust
                                                                                                                                  - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                        Treatment Plan
                                 Source of Risk




                                                                                                                                                                                                                                                                                                      Responsibility
         Department or




                                                                                                                                                                       Consequence




                                                                                                                                                                                     Level of Risk




                                                                                                                                                                                                                                        Action / Risk
                                                                                                                  Measures in
                                                                     Description




                                                                                                                                                                                                                                                                                   review date




                                                                                                                                                                                                                                                                                                                         Date on the
                                                                                                                                                                                                                                                                                   Timescale /
                                                                                                                                                                                                     Risk Score
                                                                                                                                                     Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                       Cost (£)




                                                                                                                                                                                                                                                                                                                         register
                                                                                                                  Control

                                                                                                                  place
                                                                     Risk
                                                  With the withdrawal of the Southern Cluster
                                                  LSP, EDS are renegotiating its contracts with
                                                  its customers. EDS are reviewing with                                                                                                                           Pathology replacement procured and
                                                  customers the development of existing product                                                                                                                   implementation underway with 2009 live date.
                                                  set and support charges. EDS have                                                                                                                               Business cases underway for Pharmacy 2008
                                                  negotiated 3 year contract to December 2011                                                                                                                     target date. Maternity business case
                                                  therefore reduces the risks considerably,                                                                                                                       provisionally 2009 dependent upon EDS                                            Deputy
                                                  although support costs are still likely to    SW PIMTEG, Capital Control Group and Trust        Possible                                                        development and cost profile. Likewise for                      2008 and        Director of
139 Trustwide            Local Contract           increase due to decreasing customer base      Board                                               (3)           Moderate (3)       Low              9           SALP CDS production system.                         TBA           2009             IM&T              9/18/2008

                                                                                                                                                                                                                  Board are aware of issues; Monitor aware of
                                                                                                                                                                                                                  issues; PCTs Aware cost reduction                                               Director of
                                                                                                                                                                                                                  programmes are in place. A medium term                                          Finance &
                                                                                              Internal Controls: Budgetary control process;                                                                       strategy has been approved by the board and a                                   Business
                                                                                              Board sign off of budget; Directorate sign off of   Possible                                                        3 year savings programme has been developed                                    Developmen
103 Finance              Risk Assessment          Overspend                                   budgets; Monthly Accounts produced                    (3)           Moderate (3)       Low              9           and is in the process of implementation.              0         On-going             t               2/16/2006
                                                                                                                                                                                                                  In house evening security service is operational
                                                                                                                                                                                                                  from 8pm until 5am - 7 days a week. Daytime
                                                                                                                                                                                                                  Security is provided 9am to 5.30 pm. Monday to
                                                                                                                                                                                                                  Friday. A review is taking place between
                                                                                                                                                                                                                  October - December to re-evaluate the service.
                                                                                                                                                                                                                  Service review complete service will expand to                                  Divisonal
                                         Security - There is no 24 hour cover for                                                                 Possible                                                        24/7 from August following recruitment of                                       Manager -
17 Trustwide             Risk Assessment internal security incidents.                         Full time LSMS and team of 7 security staff           (3)           Moderate (3)       Low              9           security staff                                     140000       Ongoing          Facilities
                                                                                                                                                                                                                                                                                                  Director of
                                                                                                                                                                                                                  Future developments of detailed planning                                        Finance &
                                                                                         Improved capital programme implementation                                                                                process. Employment of external consultants to                                  Business
                                                                                         management in terms of resource and                Possible                                                              support contract negotiations. Updated                                         Developmen
102 Finance              Risk Assessment Capital Programme overspend                     experience.                                           (3)                Moderate (3)       Low              9           business planning process.                            0         Ongoing              t               2/16/2006
                                                                                         The Information Governance Manager reports
                                                                                         to the Deputy Director of IMT, and is
                                                                                         responsible for the day-to-day management of
                                         Information Governance is a framework which IG. along with Data Protection Officer,
                                         pulls together all the requirements, standards Freedom of Information Lead, Trust Records
                                         and best practice that apply to the handling of Manager and advisory IMT Security Officer, is
                                         personal information within the NHS.            responsible for ensuring that both Legislation
                                         • Caldicott                                     and Trust policy are complied with, writing
                                         • Confidentiality Code of Practice              policies and procedures, identifying additional
                                         • Controls Assurance – Records Management resources, training and awareness, and
                                         and IMT                                         processing the action plan to ensure year on
                                         • Data Protection Act 1998                      year improvement.
                                         • Freedom of Information Act 2000                                                                                                                                        Annual Information Governance Review utilizing
                                         • Information Quality Assurance                 Annual Review using NHS Information                                                                                      the 'NHS Toolkit' followed by Implementation of
                                         • Information Security Management               Governance Toolkit. 2007 score 75%                                                                                       resulting action plan.
                                         (Availability, Confidentiality and Security)                                                                                                                             • The implementation of Department of Health
                                         • Records Management                            Ongoing Internal and External Audit. External                                                                            advice and guidance
                                         Failure to meet legislated requirements.        accreditation. Information Goverenance                                                                                   • Compliance with the law                                                      Information
                                         Unable to provide continued support for patient Committee. Annual PBR audit of clinical                                                                                  • Year on year improvement plans                                               Governance
97 IM&T                  National Target care and loss of income                         coding                                            Unlikely (2)            Major (4)         Low              8                                                                 0         Ongoing         Manager
                                                                                         All baths have mixer taps fitted (total body
                                                                                         immersion). Warning signs are fitted to all
                                                                                         hand basins. Mixer taps are fitted in higher risk
                                         Safe hot water and hot surface temperatures. areas.              Surface temperatures are
                                         Compliance with NHS Estates Health              controlled in higher risk areas. Risk
                                         Guidance Note, “Safe hot water and hot          assessment for the Trust was carried out in                                                                              Plan to install mixer taps and compliant surface                                 Head of
93 Facilities            SABS alert      surface temperatures".                          December 2004.                                     Likely (4)             Minor (2)         Low              8           temperatures in higher risk areas first.           10000        On-going         Estates




                                                                                                                                                                                                                                                                                                                                       6
                                                                                                                                             Royal Devon Exeter NHS Foundation Trust
                                                                                                                                             - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                                       Treatment Plan
                                 Source of Risk




                                                                                                                                                                                                                                                                                                                    Responsibility
         Department or




                                                                                                                                                                                   Consequence




                                                                                                                                                                                                    Level of Risk




                                                                                                                                                                                                                                                       Action / Risk
                                                                                                                              Measures in
                                                                         Description




                                                                                                                                                                                                                                                                                                 review date




                                                                                                                                                                                                                                                                                                                                       Date on the
                                                                                                                                                                                                                                                                                                 Timescale /
                                                                                                                                                                                                                    Risk Score
                                                                                                                                                                 Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                                     Cost (£)




                                                                                                                                                                                                                                                                                                                                       register
                                                                                                                              Control

                                                                                                                              place
                                                                         Risk
                                                                                        Risk assessments undertaken against all 25
                                                                                        conditions of authorisation. All actions in
                                                  Non compliance with Monitor Terms of  place. Signed off by the Board and scrutinised                                                                                                                                                                            Chief
80 Trustwide             Monitor target           Authorisation                         by Monitor.                                    Unlikely (2)                            Major (4)           Low               8           None needed                                         N/A        Ongoing         Executive
                                                                                        Guidelines. All drugs checked prior to being
                                         Student nurse causing harm to a patient by     given by qualified member of staff. Students                                                                                                                                                                            Director of
                                         administering incorrect or wrong dose IV drugs supervised by qualified nurse who has                                                                                                                                                                                   Nursing &
105 Trustwide            Risk Assessment under supervision.                             undertaken IV training.                        Unlikely (2)                            Major (4)           Low               8  No further action needed.                                     0         Ongoing        Patient Care          2/23/2006
                                                                                                                                                                                                                        Trust emergency preparedness plan has been
                                         Contingency Planning - There is a risk that an                   The estates department have plans in place to                                                                 amended and business continutity features
                                         event will occur which will have an effect in the                deal with business continuity issues. Sttafing                                                                strongly within it.Revised emergency
                                         Trust's ability to continue its normal business.                 and resource issues are covered in the Trust                                                                  preparedness plan onerevised and taken                                                   Chief
                                         This could take one of 3 forms - loss of staff,                  flu plan. Directorates have completed                                                                         through governance group and will be launched                                           Operating
108 Trustwide            Risk Assessment loss of facilities or loss of services.                          business continuity impact analyses.             Unlikely (2)        Major (4)           Low                8 in January 2009.                                              0          Jun-09          Officer             3/16/2006
                                                                                                          All measures are in place with regard to the
                                                                                                          recommendations apart from a solution with a
                                                                                                          lower concentration of sodium is being used.
                                                                                                          Although the likelihood of this leading to a
                                                                                                          hyponatraemia episode is slightly greater, with
                                                                                                          all of the other measures, particularly the
                                                                                                          monitoring guidelines that are followed closely,
                                                                                                          the risk is minimal.
                                                  Non-compliance with patient safety alert
                                                  number 22 - hyponatraemia - There is concern            The reasons for the choice of solution is that
                                                  with regard to the choice of IV fluids                  the solution recommended by the alert has a
                                                  recommended. In particular, there are risks in          high concentration of chloride, which could lead
                                                  relation to the high chloride content, and in           to complications, and due to the constituents of
                                                  addition, this fluid is an irritant, particularly for   the recommended fluid there is a likely higher
                                                  small children and could cause burn injuries if         incidence of extravasation of cannulas, leading
                                                  the there is extravasation. The risk relates to         to further risks for children.                                                                                                                                                                         Clinical
    CWH -                                         patient risk rather than non-compliance with                                                                                                                                   Follow revised local guidance and source                                        Director
134 Trustwide            SABS alert               the alert                                                                                                  Unlikely (2)      Major (4)           Low               8           different fluid solutions                            0         Ongoing           CWH                9/4/2007
                                                                                                                                                                                                                                 Meetings with Devon PCT to seek a way
                                                                                                                                                                                                                                 forward. Other Trusts’ procedures to be
                                                                                                                                                                                                                                 reviewed. Policy on communicating and
                                                                                                          Radiology reports are reported on by qualified                                                                         actioning xray reports written, for
                                                  Meet the requirements of the NPSA SPN016                staff and paper reports sent out. All staff have                                                                       ratification/circulation in February 2009. Safety
                                                  Early identification of failure to act on               access to and training on PACS and can view                                                                            net procedures to be developed within each                                      Medical
147 Trustwide            CAS Alert                radiological imaging reports                            xrays and reports on screen                      Unlikely (2)        Major (4)           Low               8           clinical area affected.                                        Ongoing          Director            1/21/2009
                                                                                                                                                                                                                                 Risk assessment taken to Governance
                                                  The storage of alcohol rub in metal cabinets -                                                                                                                                 Committee on 17th August 2005. Committee
                                                  Fire risk – if not complying with NHSE notice.          No bulk storage outside NHS logistics. No                                                                              agreed to take the risk of not introducing metal                               Head of
95 Trustwide             SABS alert               Risk of spills that may ignite.                         smoking policy in the Trust.                       Unlikely (2)     Moderate (3)       Very Low            6           cabinets.                                            0           N/A           Estates
                                                                                                                                                                                                                                                                                                                 Clinical
                                                                                                          Most areas using correct paperwork but a few                                                                                                                                                         Directors /
                                         Embedding consent processes into everyday                        may not be undertaking consent in the correct                                                                          Audit the consent processes via Directorate                                   Directorate
 2 Trustwide             Risk Assessment clinical practice                                                way                                                Unlikely (2)     Moderate (3)       Very Low            6           Governance Groups                                    0         On-going       Managers

                                  Plain bupivacaine 0.25% 50ml syringes
                                  labelled "For Epidural Use" are used for
                                  infiltrative analgesia in other areas (i.e.
                                  paravertebral infusions, nerve block catheter
                                  infusions etc). Confusion over type of                                                                                                                                                                                                                                         Chair of
                                  analgesic technique in situe. Patient                                                                                                                                                                                                                                        Critical Care
    Surgery /                     deterioration may be attributed to side effects                                                                                                                                                Improve labelling of administration sets. Adapt                                Divisional
    Recovery /                    of epidural analgesia when no epidural present Staff awareness. Syringe colour correctly                                                                                                       acute pain guidelines. Staff awareness through                                Governance
152 critical care Risk Assessment and deterioration caused by another problem. identifies contents.                                                          Unlikely (2)     Moderate (3)       Very Low            6           training                                             0         Ongoing           Group              3/5/2009




                                                                                                                                                                                                                                                                                                                                                     7
                                                                                                                              Royal Devon Exeter NHS Foundation Trust
                                                                                                                              - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                        Treatment Plan
                                 Source of Risk




                                                                                                                                                                                                                                                                                                   Responsibility
         Department or




                                                                                                                                                                   Consequence




                                                                                                                                                                                    Level of Risk




                                                                                                                                                                                                                                        Action / Risk
                                                                                                               Measures in
                                                                 Description




                                                                                                                                                                                                                                                                                review date




                                                                                                                                                                                                                                                                                                                      Date on the
                                                                                                                                                                                                                                                                                Timescale /
                                                                                                                                                                                                    Risk Score
                                                                                                                                                Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                    Cost (£)




                                                                                                                                                                                                                                                                                                                      register
                                                                                                               Control

                                                                                                               place
                                                                 Risk
                                                                                                                                                                                                                                                                                               Director of
                                                                                                                                                                                                                 Medium term financial plan delivering surpluses.                              Finance &
                                                                                                                                                                                                                 Financial recovery plan delivering savings.                                   Business
                                                                                           Monthly cash flow and rolling 24 month cash                                                                           Capital loan in place. Working capital facility                              Developmen
79 Finance               Risk Assessment Cash flow insufficient to meet liabilities        flow taken to the board. Capital loan.             Rare (1)       Catastrophic (5) Very Low               5           renewed.                                            0         On-going             t
                                                                                                                                                                                                                                                                                               Director of
                                                                                                                                                                                                                                                                                               Finance &
                                                                                                                                                                                                                                                                                               Business
                                                                               Borrowing levels maintained below 50% of                                                                                                                                                                       Developmen
78 Finance               Risk Assessment Borrowing ratios breached             limit.                                                         Rare (1)       Catastrophic (5) Very Low               5           No action at present                                0         Ongoing              t               2/16/2006
                                                                               All telephones on the Heavitree site have been
                                                                               labelled 9999 for medical emergencies/cardiac
                              Emergency telephone number change from           arrest. Inadvertent dialling of 2222 will be
                              2222 to 9 999 on Heavitree site only. This is in immedicately picked up by telecomms and call
                              contravention of NPSA alert standardising        transferred to the ambulance service.
                              crash numbers to 2222. However, there is no Ambulance station located opposite Heavitree                                                                                                                                                                         Director of
    Heavitree                 crash team available at Heavitree therefore      hospital therefore time to arrival at scene                                                                                                                                                                     Nursing &
143 Hospital  Risk Assessment 9999 should be used.                             minimised.                                                     Rare (1)       Catastrophic (5) Very Low               5           N/A                                                 0         On-going       Patient Care          7/28/2008
                                                                               Performance managed through Project
                              Not achieving service improvements as            Steering Groups with designated Executive                                                                                         Strong connection to LDP, SDS, HC and
    Service                   outlined in national bids/Service Development Lead, Project Lead and Managerial Lead, Audit                                                                                        Monitor . Service Development map links                                        Chief
    Developme                 map. Risk of funding recalled, key targets not trail maintained through Finance dept for all                                                                                       development outcomes and reports on ComEx                                     Operating
92 nt         Risk Assessment achieved                                         modernisation projects                                         Rare (1)          Major (4)        Very Low            4           site                                                0         On-going         Officer
                                                                                                                                                                                                                 Business case being written for purchase of
                                                                                                                                                                                                                 new ultrasound machine to assist chest drain
                                                                                                                                                                                                                 insertion. Lead clinician undergoing training in
                                         Meet the requirements of the NPSA RRR03           Local guidelines developed, staff awareness                                                                           January 2009 in order to train small cohort of
                                         regarding risks surrounding Chest Drain           and training being carried out, e.g. junior                                                                           physicians (train the trainer)                                                 Medical
146 Trustwide            CAS Alert       insertion                                         doctors. Clinical Leads assigned in each area      Rare (1)          Major (4)        Very Low            4                                                              TBD        Aug-09           Director            1/21/2009
                                          National guidance requires a change to a 2%
                                         chlorhexidine wipe strength as this is more
                                         effective. Unfortunately, the only 2%
                                         chlorhexidine product licensed specifically for
                                         skin disinfection, available via NHS Supply
                                         Chain, is in the form of single use, sterile
                                         applicator which we currently use for skin prep
                                         prior to more major and less common
                                         procedures, such as central line and epidural
                                         line insertion. For the much more common
                                         and minor procedures of injection, cannulation
                                         and venepuncture all that is required is a
                                         single use, individually wrapped impregnated
                                         swab/wipe of the type we have used in the
                                         past but impregnated with 2%, instead of 0.5%
                                         chlorhexidine. However, the only ones
                                         available are licensed for use on medical
                                         devices, not skin. The difference between the
                                         wipe and the more expensive applicator is that,
                                         although individually wrapped and single use,
                                         the wipe is not sterile whereas the applicator    Continuous bacteraemia surveillance is
                                         is. It must be recognised that the skin           undertaken to monitor infection rates in
                                         disinfectant used nationwide prior to major       patients with peripheral venous cannulae (pvc).                                                                                                                                                     Director of
                                         surgery is not sterile either and is decanted     There has not been an increase in cases                                                                                                                                                              Infection
                                         from multiuse bottles, which suggests strongly    associated with pvc since the introduction of he                                                                                                                                                   Prevention &
153 Trustwide            Risk Assessment that lack of sterility is not an issue.           wipes.                                             Rare (1)        Moderate (3)       Very Low             3 N/A                                                          0         Ongoing           Control            3/5/2009




                                                                                                                                                                                                                                                                                                                                    8
                                                                                                                                  Royal Devon Exeter NHS Foundation Trust
                                                                                                                                  - Trust Risk Register as at 30th June 2009




                                                                                                                                                                                                                                        Treatment Plan
                                Source of Risk




                                                                                                                                                                                                                                                                                                     Responsibility
         Department or




                                                                                                                                                                     Consequence




                                                                                                                                                                                      Level of Risk




                                                                                                                                                                                                                                        Action / Risk
                                                                                                                   Measures in
                                                                     Description




                                                                                                                                                                                                                                                                                  review date




                                                                                                                                                                                                                                                                                                                       Date on the
                                                                                                                                                                                                                                                                                  Timescale /
                                                                                                                                                                                                      Risk Score
                                                                                                                                                 Likelihood
         Trustwide
Number




                                                                                                                                                                                                                                                                      Cost (£)




                                                                                                                                                                                                                                                                                                                       register
                                                                                                                   Control

                                                                                                                   place
                                                                     Risk
                                                                                               Informtion Governance Committee and
                                                                                               extraordinary group consisting of Director of
                                                                                               Finance & Business Development, Medical
                                                                                               Director, Head of Patient Governance , Dep                                                                          Full Business Case being developed for
                                                                                               Director of IMT and other senior IMT team                                                                           replacement following procurement. Internal
                                                                                               members to review issues. Letter sent to all                                                                        solution developed and implemented across all
                                                 PLATO clinical documentation system has       GPs advising of situation in addition to                                                                            specialties as at 29 05 09. Theere is some
                                                 developed a number of software bugs that is   Trustwide circulation including Clinical                                                                            residual functionality within PLATO                                            Deputy
                                                 causing various system errors relating to     Directors, Divisional Managers, All PLATO                                                                           documentation such as burst dictation used                                    Director of
154 Trustwide            Local Contract          patient details etc.                          users to be extra vigilant.                     Rare (1)          Minor (2)         Very Low            2           within orthopaedics for their ward round notes.    TBA        Mar-10             IMT               6/4/2009
                                                                                                                                                                                                                                                                                                 Director of
                                                                                                                                                                                                                                                                                                 Finance &
                                                                                                                                                                                                                   Private patient income dropping due to waiting                                Business
                                                                                                                                                                                                                   times falling, NHS income increasing. No further                             Developmen
76 Finance               Risk Assessment Private Patient Cap                                   Monitoring by Finance function                  Rare (1)       Insignificant (1)    Very Low            2           action deemed necessary                             0         Ongoing              t

                                Paediatric saturation probes (single use) areLeads are cleaned after each use with an
                                only reused in the triage environment in ED. alcohol wipe. Probes are used until the
                                                                             adhesion deteriorates beyond use, and are
                                This is historic practice due to the high volume
                                of patients, and the need to take oxygen     therefore changed 2-3 times per day. This
                                                                             formally has been risk assessed with the
                                saturation as a routine observation as part of                                                                                                                                                                                                                  Dirvisoonal
    Medical                     triage for the overwhelming majority of      infection control team who have agreed this is                                                                                        Attempting to source a cost-effective re-usable                              Manager -
149 Directorate Risk Assessment paediatric presentations at ED.              acceptable. The agreed risk rating is attached.                   Rare (1)          Minor (2)         Very Low            2           alternative for paediatric triage.                 TBA        Sep-09          Medicine             3/2/2009
                                                                             Peak flow meters are wiped between each
                                                                             patient with alcohol wipes. A new bacterial
                                Peak flow meters (Single use) Reused as they filter is used each time. Patients who require                                                                                                                                                                     Dirvisoonal
    Medical                     are used in these areas usually for 1 or 2   more recordings are supplied with a single                                                                                            Acceptable practice from an infection control                                Manager -
150 Directorate Risk Assessment readings only.                               patient use meter.                                                Rare (1)          Minor (2)         Very Low            2           perspective.                                        0         Ongoing         Medicine             3/2/2009




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