South Tyneside and Sunderland NHS Trust
NHS / Health Body
Action Planned
• The company's Clinical Application Specialist (CAS) will provide on-site training and support for a total of 4 weeks. • The training programme will incorporate the alarm classifications and the importance of maintenance of the lead attachments to ensure optimal performance of the monitors. • The company will also deliver 'Train the Trainer' with individuals to ensure future new starters can be trained following this initial period. (AI summary)
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Dear 15th and yet
To summarise the training plan, the company's Clinical Application Specialist (CAS) will be on- site for a total of 4 weeks to provide on-site training and support: The training will commence on the department approximately 2 weeks before the roll out, to allow a high percentage of staff to be trained prior to the go live date: There will be a further 2 weeks support the implementation and post go live stage: The training programme will incorporate the alarm classifications and the importance of maintenance of the lead attachments to ensure optimal performance of the monitors_ The company will also deliver 'Train the Trainer" with individuals to ensure future new starters can be trained following this initial period. The CAS will then return to the Trust 3-4 weeks post go live to discuss and amend any requested configuration changes on the monitors_ Following further visits and training may be requested if required:. trust this provides you with the assurance regarding the provision of refresher training to our staff. With respect to additional learning arising from the evidence heard at Inquest; can assure you that the cardiology team are vigilant in reviewing both "advisory" 'warning" and "crisis" alarms and attending to the patient immediately to check for any artefactllead detachment; to ensure optimal monitoring conditions to detect arrhythmias_ This will be reinforced in the training for the new monitoring system. There was additional learning arising from the evidence provided byl GE Healthcare and medical expert_ The cardiac monitor in question has multi lead ECG analysis, meaning that it collects data from all four leads to analyse the rhythm utilising the automated inbuilt detection algorithms. When malfunction of Mr: Collings' cardiac monitor was suspected by the clinical team, our electronics department isolated the monitor for inspection and testing and retrieved the electrocardiogram (ECG) waveform data from the device log file. However, in this instance, the data was only printed off from one of the four monitoring leads, which was insufficient for full review by the manufacturer. In future, our Hospital Biomedical Engineering Manager will clarify with manufacturers exactly what data needs to be obtained from the device log file to allow a full and thorough inspection. As you will note, the Trust is addressing the shortfalls highlighted during our investigation and the Inquest;, in order to prevent future deaths in similar circumstances Progress of the actions detailed in this letter will be overseen by our Executive Director of Nursing, Midwifery and Allied Health Professionals, who will also keep me briefed and report to the Trust's Clinical Governance Steering Group. trust this information provides assurance to you that the Trust has taken appropriate action to mitigate any future patient safety issues with regard to the monitoring and observation of patients within cardiology: would also like to take this opportunity to offer my sincere condolences to Mr Collings' family on behalf of myself and the Trust:
To summarise the training plan, the company's Clinical Application Specialist (CAS) will be on- site for a total of 4 weeks to provide on-site training and support: The training will commence on the department approximately 2 weeks before the roll out, to allow a high percentage of staff to be trained prior to the go live date: There will be a further 2 weeks support the implementation and post go live stage: The training programme will incorporate the alarm classifications and the importance of maintenance of the lead attachments to ensure optimal performance of the monitors_ The company will also deliver 'Train the Trainer" with individuals to ensure future new starters can be trained following this initial period. The CAS will then return to the Trust 3-4 weeks post go live to discuss and amend any requested configuration changes on the monitors_ Following further visits and training may be requested if required:. trust this provides you with the assurance regarding the provision of refresher training to our staff. With respect to additional learning arising from the evidence heard at Inquest; can assure you that the cardiology team are vigilant in reviewing both "advisory" 'warning" and "crisis" alarms and attending to the patient immediately to check for any artefactllead detachment; to ensure optimal monitoring conditions to detect arrhythmias_ This will be reinforced in the training for the new monitoring system. There was additional learning arising from the evidence provided byl GE Healthcare and medical expert_ The cardiac monitor in question has multi lead ECG analysis, meaning that it collects data from all four leads to analyse the rhythm utilising the automated inbuilt detection algorithms. When malfunction of Mr: Collings' cardiac monitor was suspected by the clinical team, our electronics department isolated the monitor for inspection and testing and retrieved the electrocardiogram (ECG) waveform data from the device log file. However, in this instance, the data was only printed off from one of the four monitoring leads, which was insufficient for full review by the manufacturer. In future, our Hospital Biomedical Engineering Manager will clarify with manufacturers exactly what data needs to be obtained from the device log file to allow a full and thorough inspection. As you will note, the Trust is addressing the shortfalls highlighted during our investigation and the Inquest;, in order to prevent future deaths in similar circumstances Progress of the actions detailed in this letter will be overseen by our Executive Director of Nursing, Midwifery and Allied Health Professionals, who will also keep me briefed and report to the Trust's Clinical Governance Steering Group. trust this information provides assurance to you that the Trust has taken appropriate action to mitigate any future patient safety issues with regard to the monitoring and observation of patients within cardiology: would also like to take this opportunity to offer my sincere condolences to Mr Collings' family on behalf of myself and the Trust: