What Can Go Wrong? How Often? How Bad? Is there a Need for Action?

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Presentation transcript:

What Can Go Wrong? How Often? How Bad? Is there a Need for Action?

Stage 2 - Meeting Preparation Task 3 – Risk Assessment Meeting Task 4 – Review and Follow-up Task 1 – Planning the Risk Assessment Task 2 - Meeting Preparation

Ward nurse identifies and assesses patient in need of treatment Ward treatment Bleep management / HaN Team assessment and resource allocation HaN Team assessment HaN Team treatment resource allocation HaN Team treatment Example of Top Level Activity Mapping Example of Second Level Activity Mapping (Treatment of patients needing unscheduled care) Patient evaluation HaN Team arrival and handover from Day team Planned treatment (e.g. taking blood samples) Acute Admissions Handover to Day team and HaN Team departure Bed Management Treatment of patients needing unscheduled care Risk Assessment of Patients on Wards Implementation of HaN Planned tests/treatment

Step 1 - Select activity to assess Step 4 – Select relevant hazard to assess Step 5 – Identify causes, patient safety consequences and control (Record in log sheet columns 3, 4 & 5) Step 6 – Assess hazard’s risk and determine the need for action (Record in log sheet columns 6, 7 & 8) Step 7 – Develop recommendations and re-assess risk (Record in log sheet columns 9, 10,11 and 12) Assessment complete Step 9 - Another Activity? Yes No Step 8 – next Another hazard? No Step 2 - Describe activity (Document in top section of log sheet) Step 3 – Identify relevant hazards (Record in log sheet column 2)

HaN Solution A&E ITU Diagnostic services (X-ray, pathology) Pharmacy Medical records Theatres Paediatrics O&G Day Shift Teams Ambulance service Mental Health Trust Internal (Clinical External Equipment Library Internal administrative Bed Management Medical Physics Department

HaN Team receive handover from day staff Bleep management Bed management Completion of handover form on wards Inpatient unscheduled care Emergency admissions Handover to day staff Routine / planned care

Figures used in Introductory slides (HaN Risk Assessment Guide)

HaN Team arrival and handover from Day team Planned treatment (e.g. taking blood samples) Acute Admissions Handover to Day team and HaN Team departure Bed Management Treatment of patients needing unscheduled care Risk Assessment of Patients on Wards Implementation of HaN Planned tests/treatment

Example of Second Level Activity Mapping (Treatment of patients needing unscheduled care) Ward nurse identifies and assesses patient in need of treatment Ward treatment Bleep management / HaN Team assessment and resource allocation HaN Team assessment HaN Team treatment resource allocation HaN Team treatment Patient evaluation Treatment of patients needing unscheduled care