scottish patient safety programme highlight report - NHS Lanarkshire

SCOTTISH PATIENT SAFETY PROGRAMME
HIGHLIGHT REPORT
Medicines Management Amber to Green. Very good progress in medicines reconciliation in Older Peoples
Receiving at Monklands Hospital and sustained improvement achieved. Further tests of change being
undertaken at Wishaw and improvement being noted there too. Increasing medical staff involvement.
MMP3c: Anticoagulation: INR >6, while scale has been altered, the results are demonstrating some
variation and greater understanding continues to be sought re same with review of case notes and early
notification from labs to facilitate this process.
MMP2: FMEA: Repeat / recalculated FMEA at Wishaw demonstrating improvement with a decrease of 46%
and 30% at Monklands. This work is shared across NHS Lanarkshire.
MMP1: Medication Reconciliation: Medicines reconciliation continues to have challenges within acute
receiving units as this continued to be viewed as Pharmacy led. An improvement team focussing on Wishaw.
MMP1 Custom Measure: Parallel work has been undertaken in Older Peoples Receiving at Monklands
Hospital and this is seeing some excellent results and sustained improvement. Lessons are being learned
from this unit.
Peri operative All green, except surgical brief which is amber to green. Data now beginning to be reported
as per general ward and excerpts from this data demonstrating spread and improvement following peri
operative dialogue.
POP1:DVT prophylaxis: All sites at target
POP2: Antibiotic prophylaxis: Excellent progress - at target.
POP3: Glucose control: Still some difficulty in achieving this – type 2 diabetic patients and normal level of
control and emergency activity. Clinical decision focussed.
POP4: Beta blockers: Sustained improvement Monklands although slight recent dip. At target Hairmyres,
not yet at target Wishaw.
POP5: Normothermia: At target at three sites
POP6: Skin preparation / hair clipping: 100% compliance. Fully spread and no razors available.
POP7: Surgical brief: Monklands and Wishaw at target with progress at Hairmyres. Surgical Pause: All
theatres, all sites. Excellent progress and sustaining same
All data being reported as per general ward to more easily inform improvement plans