City Hospitals Sunderland
NHS / Health Body
Action Planned
The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the Acute Medical Unit to base ward has been introduced. The Trust will hold a clinical symposium in the autumn regarding VTE management. (AI summary)
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Dear Mr-Winter Regulation 28 Report to Prevent Future Deaths write in response to the correspondence received from you on 13th March 2014 following the inquest into the death of Mrs Jean James. acknowledge the failures that led to Mrs James' death and offer my sincere apologies to her family: To mitigate against future risk the Trust has undertaken the following actions:
1) We have reviewed the hospital information system, known as MEDITECH V6 to find solution to prevent further risk for patients who on assessment are at risk of developing venous thromboembolism episode (VTE): The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk The medical staff will be required to complete the prescription for the thromboprophylaxis medication at this point in the process_ will not be able to move out of the screen unless has been prescribed or a rationale has been provided for not prescribing the medication, this may be required for patients with contraindicated co-morbidities_ Additionally on the medication administration record (MAR) there will be an alert identified should the patient be at risk of VTE. This will be an extra prompt for nursing staff to ensure the prescribed medication is being administered_ This system is currently in the test phase and anticipate implementation by the end of
2014. Neurophysiology Department Sunderland Eye Infirmary 8 Day Case Unit Chairman: John N Anderson QA CBE In association with the Universities of Newcastle, Sunderland and Northumbria wwwsunderland nhsuk WzI824 They drug May abour sitive _ 1 O1SABLe9
The clinical teams will be alerted to this development by: an all users electronic message briefings within clinical teams have also directed our Clinical Governance Department to undertake an audit of the system to ensure practice is embedded_
2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights indicators regarding the patient's healthcare needs, and treatment plan:
3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.
4) The Trust has a VTE policy based on NICE guidelines and we are currently reviewing the policy to encompass the technical changes made to the VTE assessment and prescribing process_ will hold a Trust wide clinical symposium in the autumn to ensure staff have the opportunity to discuss current issues regarding the management of patients at risk of VTE. acknowledge that cannot provide assurance that all actions have been resolved and request that you accept this letter as an interim position statement Once all of the actions are complete will write to you to provide confirmation and assurance Please accept this letter as evidence that the organisation has reflected on and learnt from the events related to Mrs James' death: Finally once again would like to reiterate my apologies to Mrs James' family and offer sincere condolences_
1) We have reviewed the hospital information system, known as MEDITECH V6 to find solution to prevent further risk for patients who on assessment are at risk of developing venous thromboembolism episode (VTE): The proposal is for the VTE assessment screen to automatically move to the prescription screen if a patient has been identified as being at risk The medical staff will be required to complete the prescription for the thromboprophylaxis medication at this point in the process_ will not be able to move out of the screen unless has been prescribed or a rationale has been provided for not prescribing the medication, this may be required for patients with contraindicated co-morbidities_ Additionally on the medication administration record (MAR) there will be an alert identified should the patient be at risk of VTE. This will be an extra prompt for nursing staff to ensure the prescribed medication is being administered_ This system is currently in the test phase and anticipate implementation by the end of
2014. Neurophysiology Department Sunderland Eye Infirmary 8 Day Case Unit Chairman: John N Anderson QA CBE In association with the Universities of Newcastle, Sunderland and Northumbria wwwsunderland nhsuk WzI824 They drug May abour sitive _ 1 O1SABLe9
The clinical teams will be alerted to this development by: an all users electronic message briefings within clinical teams have also directed our Clinical Governance Department to undertake an audit of the system to ensure practice is embedded_
2) We have introduced a new format for clinical handover of patients from the Acute Medical Unit to their base ward. This acuity handover tool is patient focused and highlights indicators regarding the patient's healthcare needs, and treatment plan:
3) Communication between the pharmacy team and escalation of omissions is currently the subject of an internal review where the team are in the process of identifying workable solutions.
4) The Trust has a VTE policy based on NICE guidelines and we are currently reviewing the policy to encompass the technical changes made to the VTE assessment and prescribing process_ will hold a Trust wide clinical symposium in the autumn to ensure staff have the opportunity to discuss current issues regarding the management of patients at risk of VTE. acknowledge that cannot provide assurance that all actions have been resolved and request that you accept this letter as an interim position statement Once all of the actions are complete will write to you to provide confirmation and assurance Please accept this letter as evidence that the organisation has reflected on and learnt from the events related to Mrs James' death: Finally once again would like to reiterate my apologies to Mrs James' family and offer sincere condolences_