Trust Board papers November 2012 - Barking Havering and ...

SPECIALISTS MEDICINE RISKS
SUPPORT SERVICES RISKS
4
6
4
3.5
6
5
3
2.5
2
1.5
1
0.5
0
0
1 1
Low Moderate High Extreme
4
3
2
1
0
0 0
Low Moderate High Extreme
0
New Risk on the Corporate Risk Register
Trust Reference: 343
Area: Directorate Anaesthetic:
Risk: Failure to comply with NSPA Alert to change over to a non-Luer connection on needles used for Neuroaxial procedures can potentially cause serious harm to patients
Controls: All current safety measures are in keeping with recommendations made by the Royal Colleges of Anaesthesia and Pharmacology. NPSA has recommended the use
of one system but this is at present untested and potentially unsafe. All Anaesthetic and Pharmacology Professional Agencies and the Medical Director for NHSL have voiced
concern in proceeding to the change without assurance of safety. Paper presented to Quality and Safety for decision on way forward where it was agreed that it would be unwise
to invest in an untested and potentially unsafe system and this would be raised with the Commissioners.
Directorates
The Directorates that are not reflected currently on the BAF have risks that are controlled within their own Directorate and mirrored on their locals risk registers. All risks are
renewed regularly.
The Directorates are increasingly building their local risk management systems by a continuous process which is demanding awareness and proactive action. The drivers are to
base each risk on reducing the likelihood and consequences of adverse impacts on agreed objectives and on increasing the opportunities for improvement.
This requires infusing risk management into organisational culture and everyday business operations including planning, reporting and governance. This is monitored by the
Clinical Governance team.
BHRUT BAF 2nd Quarter 2012: SB/PS
7