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

PRINCIPAL RISK
What could prevent the objective being
achieved
Risk no, Date on Risk Register
& Risk Scoring:
KEY EXISTING CONTROLS
What controls/systems are in
place to assist in securing delivery
of objective and managing
principle risks?
CQC REF:
RESIDUAL RISK
ASSURANCES ON
CONTROLS & IMPACT
Where we gain evidence
that our controls/systems, on
which we are placing
reliance, are effective? The
impact following assurances.
Principal Objective: To ensure the patient safety agenda is fully established in all areas of the Trust – Nursing
Risks No 251: Failure to Admission screening for all
protect our patients
elective and emergency
against Health Care
admissions.
Associated Infections Decolonisation therapy for
(HCAI’s)
known positive patients.
Limit set at 7 for MRSA Patients known to be
Bacteraemia and 59 for previously positive are flagged
on PAS.
C.difficile
Date on Register: 25.01.2010
Rating Scoring: Impact:4 x
Likelihood:4 = 16
Area: Trust
Impact on:
Patient: Poor patient outcomes
Staff: Risk to Trust reputation
affecting staff morale
Trust: In year financial risk of
every C.difficile cases over the
limit and on ability for Trust to
reach FT status
Details updated: 24.10.2012
Detailed RCA of all
bacteraemia led by DIPC.
Daily reporting on MRSA
bacteraemia numbers and
C.difficile
CQC supporting actions have
been completed
Re-launching hand hygiene
awareness training in
September
All clinical staff are being
taught and assessed on
aseptic non-touch technique
started in July 3 sessions
occurred – ( FY1 51junior
doctors trained)
8 16
Extreme Risk
RCA summary action
sheets highlights key non
compliances, screening
of patients, appropriate
decontamination of
positive patients,
documentation of such
and the practice of blood
culture taking. Training
implementation of
policies is actively
reviewed.
Internal –Internal Audit,
Infection Prevention
Control Committee
External – CQC
PROGRESS AGAINST
RISKS/ ACTION
PLAN UPDATE
What Actions are undertaken to
mitigate the actual risks?
A Trust wide RCA action plan
has been developed.
Learning from previous RCA’s
– this is included in the annual
infection prevention control
plan for 2012/ 2013
Monthly action plan is being
developed
Plans to be developed for
rapid reduction in rate of
progress in C.difficile curve
GAPS IN ASSURANCE
Where we are failing to gain
evidence that our controls /
systems, on which we place
reliance, are effective
MRSA trajectory target
breached for 2012, ( 8
incidents)
C.difficile 59 or
exceeding this target
with 38 cases mid year
GAPS IN
CONTROL
Where are we
failing to put
controls / systems
in place? Where are
we failing in making
them effective?
Targets set but
not achieved
consistently
because of lack
of understanding
and also
insufficient
implementation of
the controls.
Requires
constant
monitoring and
evaluation.
LEAD
Ian Hosein, Director of Infection Control
Full review of all C difficile
case to date to be undertaken
to determine key themes on
causation. Action to be
completed by mid Nov. for
review by DIPC
BHRUT BAF 2nd Quarter 2012: SB/PS
9