Annual Report and Financial Accounts 2010/11


Quality Report 2010/11


Patient Safety and Quality Improvement Initiatives to support medication safety and medication incident reduction during 2010/11 have included:


Omitted or delayed doses New resources to reduce the number of missed or delayed doses of medication have been written and implemented in 2010/11. In particular, the Trust prescription chart has been revised to enable accurate recording of omitted doses. Resource material to support mandatory training has been developed and small group training sessions have been held on wards led by our Medicines Management Nurse.


Medicines reconciliation In 2010/11 there has been continued work to improve documentation and encourage doctors to resolve medication discrepancies identified by pharmacists in a timely way. Liaison with primary care ensures that action taken on changes to medication in hospital is communicated in discharge letters to GP surgeries. Audits to monitor progress are routinely undertaken and reported to the Medicines Governance Committee.


Oral liquids Teaching sessions on the correct administration of oral liquid medication using purple syringes have been held on the wards by the Trust Medicines Management Nurse. Routine audit of practice has also been implemented to monitor compliance.


Safer lithium therapy Working with Development Dorset Healthcare Trust the Trust has produced Trust-wide guidelines - “Lithium in the acute hospital setting”. A newsletter


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highlighting safe practice has been circulated and resources added to the Medicines Management Intranet page.


Safer administration of insulin Guidelines, teaching materials and an amended Diabetes Prescription Chart (incorporating new NPSA guidance) were implemented in 2010/11.


The Trust has also established a Medication Incident Review Group which is multidisciplinary and meets monthly to review reported adverse incidents (actual and potential) relating to medicines, to monitor trends and recommend further action or communication of learning points where appropriate. The Medication Incident Review Group reports to Medicines Governance Committee.


Reducing Patient Falls


Patient Accidents form the largest group of all patient safety incidents reported to the NPSA via the National Reporting and Learning System (NRLS).


The NPSA category “patient accidents” includes any slips, trips or falls by patients. These may be non harm events e.g. a patient has fallen walking along a ward corridor but not sustained an injury, or a harm event when a similar incident has occurred and the patient sustained a bruise, cut or more serious injury.


The Trust has invested heavily in staff training and equipment provision over the past three years in order to reduce the number of patient falls.


In 2010/11 the Trust completed a total bed and mattress replacement programme which has resulted in all patients now being treated on an electronic profiling bed and high


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