Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
Trust Board papers November 2012 - Barking Havering and ...
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PRINCIPAL RISK<br />
What could prevent the objective being<br />
achieved<br />
Risk no, Date on Risk Register<br />
& Risk Scoring:<br />
KEY EXISTING CONTROLS<br />
What controls/systems are in<br />
place to assist in securing delivery<br />
of objective <strong>and</strong> managing<br />
principle risks?<br />
CQC REF:<br />
RESIDUAL RISK<br />
ASSURANCES ON<br />
CONTROLS & IMPACT<br />
Where we gain evidence<br />
that our controls/systems, on<br />
which we are placing<br />
reliance, are effective? The<br />
impact following assurances.<br />
Principal Objective: To ensure the patient safety agenda is fully established in all areas of the <strong>Trust</strong> – Nursing<br />
Risks No 251: Failure to Admission screening for all<br />
protect our patients<br />
elective <strong>and</strong> emergency<br />
against Health Care<br />
admissions.<br />
Associated Infections Decolonisation therapy for<br />
(HCAI’s)<br />
known positive patients.<br />
Limit set at 7 for MRSA Patients known to be<br />
Bacteraemia <strong>and</strong> 59 for previously positive are flagged<br />
on PAS.<br />
C.difficile<br />
Date on Register: 25.01.2010<br />
Rating Scoring: Impact:4 x<br />
Likelihood:4 = 16<br />
Area: <strong>Trust</strong><br />
Impact on:<br />
Patient: Poor patient outcomes<br />
Staff: Risk to <strong>Trust</strong> reputation<br />
affecting staff morale<br />
<strong>Trust</strong>: In year financial risk of<br />
every C.difficile cases over the<br />
limit <strong>and</strong> on ability for <strong>Trust</strong> to<br />
reach FT status<br />
Details updated: 24.10.<strong>2012</strong><br />
Detailed RCA of all<br />
bacteraemia led by DIPC.<br />
Daily reporting on MRSA<br />
bacteraemia numbers <strong>and</strong><br />
C.difficile<br />
CQC supporting actions have<br />
been completed<br />
Re-launching h<strong>and</strong> hygiene<br />
awareness training in<br />
September<br />
All clinical staff are being<br />
taught <strong>and</strong> assessed on<br />
aseptic non-touch technique<br />
started in July 3 sessions<br />
occurred – ( FY1 51junior<br />
doctors trained)<br />
8 16<br />
Extreme Risk<br />
RCA summary action<br />
sheets highlights key non<br />
compliances, screening<br />
of patients, appropriate<br />
decontamination of<br />
positive patients,<br />
documentation of such<br />
<strong>and</strong> the practice of blood<br />
culture taking. Training<br />
implementation of<br />
policies is actively<br />
reviewed.<br />
Internal –Internal Audit,<br />
Infection Prevention<br />
Control Committee<br />
External – CQC<br />
PROGRESS AGAINST<br />
RISKS/ ACTION<br />
PLAN UPDATE<br />
What Actions are undertaken to<br />
mitigate the actual risks?<br />
A <strong>Trust</strong> wide RCA action plan<br />
has been developed.<br />
Learning from previous RCA’s<br />
– this is included in the annual<br />
infection prevention control<br />
plan for <strong>2012</strong>/ 2013<br />
Monthly action plan is being<br />
developed<br />
Plans to be developed for<br />
rapid reduction in rate of<br />
progress in C.difficile curve<br />
GAPS IN ASSURANCE<br />
Where we are failing to gain<br />
evidence that our controls /<br />
systems, on which we place<br />
reliance, are effective<br />
MRSA trajectory target<br />
breached for <strong>2012</strong>, ( 8<br />
incidents)<br />
C.difficile 59 or<br />
exceeding this target<br />
with 38 cases mid year<br />
GAPS IN<br />
CONTROL<br />
Where are we<br />
failing to put<br />
controls / systems<br />
in place? Where are<br />
we failing in making<br />
them effective?<br />
Targets set but<br />
not achieved<br />
consistently<br />
because of lack<br />
of underst<strong>and</strong>ing<br />
<strong>and</strong> also<br />
insufficient<br />
implementation of<br />
the controls.<br />
Requires<br />
constant<br />
monitoring <strong>and</strong><br />
evaluation.<br />
LEAD<br />
Ian Hosein, Director of Infection Control<br />
Full review of all C difficile<br />
case to date to be undertaken<br />
to determine key themes on<br />
causation. Action to be<br />
completed by mid Nov. for<br />
review by DIPC<br />
BHRUT BAF 2nd Quarter <strong>2012</strong>: SB/PS<br />
9