0
0
0
1
0
1
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
85.00%
96.00%
98.00%
93.00%
92.00%
95.00%
0
0
1
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
% shifts 'at risk staffing'
0
0
1
2
2
2
3
1
0
1
20
SIRI's (Not Pressure Ulcers)
0
0
0
0
0
0
0
0
0
0
1
Single Sex Breaches
0
0
0
0
0
0
0
0
0
0
5
Nutritional Assessments
0
0
0
2
0
0
0
0
0
0
4
Acquired Pressure Ulcers
grade 2
Acquired Pressure Ulcers
grade 3
Acquired Pressure Ulcers
grade 4
0
0
0
1
1
1
0
0
0
3
4
Track and Trigger
Major/Extreme Impact
80%
Moderate Impact
70%
Minor Impact
94%
Near miss/ No harm
94%
Major/Extreme Impact
100%
97%
99%
86%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
4 &9
Medication
Incidents
Moderate Impact
4
Falls
% End date included
8
Antimicrobial
% Correct prescription
8
Minor Impact
100%
100%
97%
100%
100%
100%
88%
95%
98%
96%
8
Near miss/No harm
Day Surgery
Ward A
Ward B
Ward D
Ward E
Ward F
Recovery
Theatres
Outpatients/POAC
OCE Ward
Hand Hygiene
Ward
8
National Cleaning Scores
R
MARS
Orthopaedics
Division
Directorate
CQC Outcomes
ANTT Injectables
MARS Quality Metrics May 2012
0
0
0
0
0
0
0
0
0
0
0%
0%
0%
0%
0%
0%
0%
0%
0%
0%
100%
100%
100.00%
100.00%
100.00%
100.00%
100.00%
96.00%
0
0
0
0
0
0
0
0
13
Ward/Department
Issue
Action
Lead
Ward F
Antimicrobial Prescribing- 70% correct prescription; 80%
duration
Identify prescribers and raise issue of poor compliance
with them individually.
Pharmacist
30-Jun-12
In progress
Recovery
88% Hand Hygiene
1) Audit repeated till 100% achieved & maintained
2) Individual staff spoken to
3) Spoke with theatre manager as most non compliant
were visitors to HDU.
Recovery & HDU
Manager
26-Jun-12
In progress
Recovery
86% ANTT Injectables
1) Update sessions arranged for all staff.
2) Identified staff nurses have now attended an ANTT
Update
Recovery & HDU
Manager
26-Jun-12
In progress
Review Date
Status