Patient Safety Issues in Gynaecology

1
Patient Safety Issues in Gynaecology

• Joanna Thomas Louise Samworth
• Saint Marys Hospital
• Manchester

2
Introduction

• Active involvement in ongoing strategies to
  improve patient safety
• Share experiences
• Highlight challenges
• Future plans and developments

3
ACCESS, ADMISSION, TRANSFER, DISCHARGE 17
CONSENT COMMUNICATION CONFIDENTIALITY 22
CLINICAL ASSESSMENT 9
BLOOD TRANSFUSION 2
INFECTION CONTROL 4
FIRE 1
LABORATORY TEST 19
INFRASTRUCTURE 37
INCIDENTS REPORTED 285
PERSONAL ACCIDENT/ INCIDENT 43
MEDICATION ERROR 17
DOCUMENTATION 32
SECURITY 3
NOT STATED 6
RESUS 1
MEDICAL DEVICE EQUIPMENT 23
SELF-HARMING BEHAVIOUR 1
TREATMENT/ PROCEDURE 39
VIOLENCE DISCRIMINATION 9
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Medication Error - Epidurals

• Problem Identification
• Increase in epidural use
• Epidural key location
• Epidurals being stopped prematurely
• Implementing Trust protocol
• Inexperienced, junior staff
• Ward staffing issues
• Professional confidence ability

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Medication Error - Epidurals

• Generating Implementing Solutions
• Support from experienced acute pain nurse and MDT
• Promotion link nurse system
• Epidural pump training sessions
• One to ones with competency framework
• Key location
• Review skill mix recruitment drive
• Review induction preceptorship
• Monitor effectiveness audit

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Medical Devices Equipment

• Centralised equipment replacement programme
• Numerous medical devices reaching end of service
• Implementing fair consistent approach to
  prioritising requirements
• Introduction of risk assessment to support
  processes risk equipment registers
• Link with Health Safety Medical Device
  Training programmes

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Medical Device Replacement Risk Assessment
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Multidisciplinary team functions

• Problem identification
• Availability of and access to doctors
• Prioritisation of case load
• Communication between professionals
• Organisational culture
• Consultant awareness and support

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Multidisciplinary team functions

• Generating Implementing solutions
• Expanding nursing roles
• Ensuring evidence base to decision making
• Skills drills
• Consultant hot days
• Ward rounds for emergency case reviews

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Promoting patient safety in Gynaecology

• Multifaceted approach
• Continuous education programmes
• Integration of clinical governance activity
• Link with individual performance professional
  development reviews
• Re-launch trigger factors
• Focus on Infection Control

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Seven Steps to Patient Safety

• Build a safety culture
• Lead and support your staff
• Integrate your risk management activity
• Promote reporting
• Involve and communicate with patients and the
  public
• Learn and share safety lessons
• Implement solutions to prevent harm
• NPSA (2004)

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Joint RCOG/ENTER MEETINGRisk Management and
Medico-Legal Issues In Womens Health25 to 26
April 2007