Local priorities to investigate

The Trust has developed a local patient safety risk-based plan.

This has been profiled using organisational data from recent patient safety incident reports, complaints, patient advice and liaison service, inquests, mortality reviews, clinical reviews and divisional engagement.

This review takes place each year and currently, we have identified the following events we must investigate through a patient safety incident investigation (PSII) in addition to the national ‘must dos’:

• Barriers to effective discharge due to issues in consideration of system elements (for example, where transport may not have been appropriate for the patient’s needs).
• Problems with the clinical care/management of diabetic patients when diabetes is not the primary reason for admission to a service or the hospital.
• Patient on an end-of-life pathway receiving unnecessary/inappropriate clinical interventions.
• Barriers to effective inclusivity (for example, effective pain assessment and relief for patients with dementia).
• Incidents with a potential for adverse impact on staff wellbeing where fundamentals of care cannot be provided due to staffing challenges.

Resource for a small number of additional PSIIs has also been allocated for any significant unexpected trend in incidents that could not have been foreseen as part of this planning exercise.