Goal 3: Measuring the Improvement 61
Theme (Continued) Next Steps Status
Goal 3:
Measuring the
Improvement
(Continued)
Patient Falls
• Quality Improvement Project using IHI Methodology will be undertaken in Ward 3a and
Ward 3b Ulster Hospital with a focus on reducing falls within New Inpatient Ward Block
where there is single room occupancy
• Staff Education Programme being developed in conjunction with Clinical Education Centre
• Further development in multiprofessional input to falls prevention within the community
which includes introduction of a falls pharmacist to the Prevention Team to review patient
medication
• Explore new pathways to identify clients at risk of falls for multifactorial falls assessment
• Introduction of new electronic Datixweb System of recording falls which will improve
reporting and monitoring of falls.
Pressure
Ulcers
• Continue to monitor compliance with the 'SKIN Bundle'
• Continue to monitor and report the number of pressure ulcer incidents, including the
number of severe pressure ulcers (Grade 3 & 4) which were considered avoidable
• Work towards reducing the number of severe avoidable facility acquired pressure ulcers
• Review the Trust Acquired Pressure Ulcer Incident Reporting and Investigation process
• Maximize learning from each incident of severe pressure damage
• Continue to provide mandatory pressure ulcer education and bespoke training in specific
clinical areas as determined through analysis of incident reports and KPI data
• Continue to monitor primary care pressure ulcer prevention strategy and monitor regional
KPI for this patient population
• Continue to recognise ward staff for their achievements in providing pressure ulcer free
care.
Venous
Thromboembolism
(VTE)
• The Trust aims to complete a Root Cause Analysis on random DVT's
• The Trust will work toward compliance with the updated NICE Guidelines (March 2018)
to include VTE risk assessment in acute psychiatry and Intensive Care.
Medicines
Management
• Pharmacy 7 day working will continue with regular review of activity at the weekends and
allocation of more staff to ward based duties where possible.
On Plan
Achieved
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On Plan
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On Plan
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On Plan
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On Plan