1. Patient Safety Issues in Gynaecology Joanna Thomas & Louise Samworth Saint Mary’s Hospital Manchester

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

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

4. Medication Error - Epidurals Problem Identification Increase in epidural use Increase in epidural use Epidural key location Epidural key location Epidurals being stopped prematurely Epidurals being stopped prematurely Implementing Trust protocol Implementing Trust protocol Inexperienced, junior staff Inexperienced, junior staff Ward staffing issues Ward staffing issues Professional confidence & ability Professional confidence & ability

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

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

7. Medical Device Replacement: Risk Assessment

8. Multidisciplinary team functions Problem identification Availability of and access to doctors Availability of and access to doctors Prioritisation of case load Prioritisation of case load Communication between professionals Communication between professionals Organisational culture Organisational culture Consultant awareness and support Consultant awareness and support

9. Multidisciplinary team functions Generating & Implementing solutions Expanding nursing roles Expanding nursing roles Ensuring evidence base to decision making Ensuring evidence base to decision making Skills drills Skills drills Consultant hot days Consultant hot days Ward rounds for emergency case reviews Ward rounds for emergency case reviews

10. Promoting patient safety in Gynaecology Multifaceted approach Multifaceted approach Continuous education programmes Continuous education programmes Integration of clinical governance activity Integration of clinical governance activity Link with individual performance & professional development reviews Link with individual performance & professional development reviews Re-launch trigger factors Re-launch trigger factors Focus on Infection Control Focus on Infection Control

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

12. Joint RCOG/ENTER MEETING Risk Management and Medico-Legal Issues In Women’s Health 25 to 26 April 2007