Local priorities to investigate
The Trust has developed a local patient safety risk-based plan.
This has been profiled using organisational data from recent patient safety incident reports, complaints, patient advice and liaison service, claims, inquests, mortality reviews, clinical reviews, divisional engagement and discussion at forums with patient and carer participation including our local VOICE group.
Through this review, we have identified the following events we must investigate through a PSII in addition to the national ‘must dos’:
- Failed discharges: patient requiring unplanned readmission related to medicines management
- Inpatients receiving shared care between specialties: incidents affecting inpatients where the care of the patient is being managed between two or more clinical specialties and where the management of the care resulted in the patient having an extended length of stay or requiring additional treatment/surgery
- Insulin and diabetes management leading to deterioration in patient’s glycaemic index requiring interventional treatment at higher level of care (level 2/3)
- Incidents occurring out of hours where the assessment of the patient was delayed and timely recognition of deterioration was not escalated appropriately.
Resource for a small number of additional PSIIs has also been allocated for any significant unexpected trend in incidents that could not have been foreseen as part of this planning exercise.
The national framework also sets out alternative methods of review, and the Trust plan includes an initial set of events for which we will use one of these methods, with an expectation that this will expand over time:
- Inpatient falls resulting in a major bone fracture
- Pressure ulcers developed in our care
- Deterioration of patient condition due to prolonged wait whilst on a surveillance programme
- Maternity incidents, adverse outcomes and externally reportable events that do not meet the threshold requirement for completion of a PSII.