The Clatterbridge Cancer Centre
NHS Foundation Trust
Sign Up To Safety
Safety Improvement Plan
June 2015
Table of Contents
Introduction ............................................................................................................................................ 3
Aims of the CCC Safety Improvement Plan ............................................................................................. 6
Delivering the CCC Safety Improvement Plan......................................................................................... 6
CCC Measurement, Monitoring and Improvement diagram .............................................................. 7
Improvement domains............................................................................................................................ 8
NHS Safety Thermometer denoted avoidable harms ......................................................................... 8
Medicines Safety ................................................................................................................................. 9
Prevention of medication errors (including prescribing and dispensing) ....................................... 9
Improve preventative measures to reduce chemotherapy induced nausea and vomiting ......... 17
Implement NICE allergy guidance ................................................................................................. 19
Improve MHRA yellow card reporting .......................................................................................... 19
Improve prevention, recognition and management of the adult deteriorating patient .................. 19
Development and Implementation of a Radiotherapy Safety Thermometer .................................. 21
Safety Improvement Plan – overview (90 day cycle) to 30th September 2015..................................... 23
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
2
Introduction
The Clatterbridge Cancer Centre NHS Foundation Trust (hereafter referred to as CCC) is committed
to delivering high quality care and to taking action to reduce harm to the patients in our care.
CCC is supporting NHS England’s national Sign Up To Safety campaign and the goal to reduce
avoidable harm by 50% and saving 6,000 lives. Through participating in Sign Up To Safety, CCC
commits it’s Trust Board and staff to:
1. Put safety first
Patient Safety is at the heart of the Trust Quality Strategy. We are committed to reducing
avoidable harm and have decided to focus our plan on the following four Improvement
Domains:

NHS Safety Thermometer denoted avoidable harms

Medicines Safety

Improve prevention, recognition and management of the adult deteriorating patient

Development and implementation of a Radiotherapy Safety Thermometer
2. Continually learn
We aim to continuously learn from our staff and our patients to improve care and safety. We will
build on our current systems to further embed a culture of learning.
We conducted our first Safety Culture Survey in August 2014. We will ensure we act on the
feedback from all staff and will continue to conduct these surveys every two years across the
Trust and more frequently in departments where we need to focus on improvement.
As a result of our first Safety Culture Survey we will introduce new systems to improve feedback
on incident reports and investigations. We will also focus more on investigating near misses.
3. Honesty
We are committed to being transparent about the quality and safety of our services. We believe
that the public have a right to know about how their specialist cancer centre is performing in the
areas that are important to them. We have developed a ‘High Quality & Safe Care’ section on our
public website which includes information on key areas of quality and safety such as harm free
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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care, waiting times, complaints, cleanliness, and patients and staff opinion of our hospitals. This
information can be found under the following headers:
Safe - Open and honest care, safety thermometer, medicines thermometer, healthcare
associated infections, patient led assessment of the care environment, incident reports, Sign Up
to Safety
Effective - Compliance with patient risk assessments, 30 day mortality post treatment
Caring - Ward nursing staff levels, patient feedback
Responsive - Compliance with cancer waiting times
Well led - Integrated performance report, staff feedback, nursing care indicators, quality
accounts
We will build on the amount of information that we provide including feedback from patients
and the public via a web questionnaire to ensure that the information is what patients want to
see and that it is easy to understand.
We plan to further develop this website to include benchmarks of how we perform against other
Trusts.
Transparency of Care
We are committed to ensure that patients who use our services can easily see information about
how we are performing and developing. Our Wards currently display a large amount of
information. We are committed to reviewing and further developing this information to ensure it
is comprehensive, is easily understandable and meets patients’ needs. We will work with our
clinical experts, ward leaders and our Patient Council to achieve this. We will then look to roll
this out to other clinical areas.
Patient Stories
We have a programme of videoing patient stories and presenting these at each Public Board
Meeting and our Council of Governors meeting. We will further develop this programme in
conjunction with our public Governors and will roll out the use of patient story videos to all
clinical departments.
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4. Collaborate
Patient Pathways
We have recently appointed a Cancer Pathways Project Manager for Network Cancer pathways,
he will lead a project to review and improve cancer pathways across the Cheshire & Merseyside
network of cancer services. The project will involve complex analysis of cancer pathways,
comparison with national best practice, development of recommendations to improve the
cancer patient’s journey through the health and social care system, reporting the
recommendations to participating hospitals and working with managers in acute hospitals to
ensure that recommendations are implemented.
Patients at the Heart of Safety
Patients are at the heart of the care and treatment that we provide and will experience and see
things in a different way to staff. We will work with patients to improve safety including
implementing a system where we encourage patients, carers and visitors to be able to easily
report any safety concerns that they have.
5. Support
Training and Development
As a result of our first Safety Culture Survey we will introduce Health and Safety briefings for
staff in all departments focusing on key health and safety themes throughout the year.
We will support staff to improve safety, including medicines safety, by implementing a new
Patient Safety Training Program
This will include:
• Root Cause Analysis Master Class for staff who investigate safety issues
• Develop a program of training in Human Factors for Healthcare
We will also review our processes and systems for providing support for staff who raise concerns
or are involved in an incident, complaint or claim.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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Aims of the CCC Safety Improvement Plan
This Safety Improvement Plan sits within the CCC’s Quality Strategy. The Quality Strategy commits
CCC and its entire staff to improve the quality of patient care that is delivered to our patients.
The Measurement, Improvement and Monitoring diagram (over page) details the work-streams
within the Trust dedicated to improving patient safety and reducing avoidable harm. We have
identified key Safety Improvement Domains to focus our improvement work over the next three
years.
Delivering the CCC Safety Improvement Plan
The Safety Improvement Plan is a three year project to improve patient safety within the
organisation
The CCC Executive sponsor for the Sign Up to Safety campaign is the Director of Nursing and Quality
and the Sign up to Safety Lead is the Clinical Governance Manager for Patients Safety (CGM-PS).
The Executive sponsor and Safety lead will lead the implementation and monitoring of the Safety
Improvement Plan.
The Clinical Governance Manager for Medication Safety is responsible for the Medicines
Improvement domain with the support of the Medicines Safety Team.
The Clinical Governance Manager for Radiation Services is responsible for the Radiotherapy Safety
Thermometer Improvement domain with the support of the Clinical Governance Manager for
Patient Safety.
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CCC Measurement, Monitoring and Improvement diagram
Improvement domains
NHS Safety Thermometer denoted avoidable harms
We record all incidences of the Four harms, specified by the NHS Safety Thermometer, which are
attributable to CCC across our three inpatient wards.
We use the following criteria for identifying CCC attributable harms:
o
VTE (Venous Thromboembolism) – patient has been an inpatient at CCC within the past 90
days.
o
Pressure Ulcers – developed 72 or more hours after the patient was admitted.
o
Falls – all patient falls are recorded.
o
CAUTI – all urinary tract infections associated with a catheter, according to our Infection
Control surveillance definitions (rather than simply reporting all patients who have a
catheter and a UTI as these may not be directly related).
Incidences of pressure ulcers, falls and VTE are reported via the Trust Incident reporting system and
a Route Cause Analysis is conducted for each harm event to establish the cause of the harm and how
(if at all) it could have been prevented. All catheterised patients are monitored for urinary tract
infections (UTI) and monitoring continues once the catheter is removed to ensure any CAUTI
developing up to three days following catheter removal is recorded.
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Medicines Safety
Our new medicines safety service promises to deliver improved medicines safety at CCC through
innovation in practice, education and implementation of harm free care initiatives.
The medicines safety team plan to focus on the following initiatives:

Prevention of medication errors (including prescribing and dispensing)

Improve preventative measures to reduce chemotherapy induced nausea and vomiting

Implementation of new NICE (National Institute for health and Care Excellence) allergy guidance

Improve MHRA (Medicines and Healthcare products Regulatory Agency) yellow card reporting
Prevention of medication errors (including prescribing and dispensing)
The medicines safety group (a collection of staff and lay members from a variety of backgrounds)
monitor medication errors and strive to implement systems and procedures to prevent them.
Medication Errors are identified through Incident Reporting, VTE Audit and the Medication Safety
Thermometer.
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Driver Diagram for Medication Errors
Action Plan for the prevention of Medication Errors
Objective
Action required
Responsibility
By date
1.Prevention of medication errors (including
prescribing and dispensing)
Teaching
MST
July 2016
CGM-Medicines Safety and
Medicines Safety Pharmacist
July 2015
Education
CGM-Medicines Safety and
Medicines Safety Pharmacist
October 2015
Review anti-emetics formulary
MST
Sept 2015
3 Implementation of new NICE (National
Institute for health and Care Excellence) allergy
guidance
Ensure action plan is adhered to and guidance is fully
implemented
MST
April 2016
4 Improve MHRA (Medicines and Healthcare
products Regulatory Agency) yellow card
reporting
Consider additional training for NMP’s and acute
oncology NP’s, ANP’s, CNS’s.
MST
July 2016
Education
MST
March 2016
MST
October 2016
Progress






2 Improve preventative measures to reduce
chemotherapy induced nausea and vomiting
Pre reg radiographers
Student Nurses
Trainee Doctors
Two yearly medicines management training
CD training
Medicines safety & yellow card for clinical
champions
Audit for CINV








5 Work with Meditech implementation CRG
teams
In process
Medicines management training
PGD pharmacology
PharmaC
Outpatients
Delamere
SPR’s
Trainee doctors
Consultants rolling half day
Integrate over all groups of implementation groups
In progress
Incident Reporting
Medicine related incidents are separated into the following three categories:

Drug error – wrong drug, wrong route, wrong dose, wrong time, wrong patient

Dispensing error – near misses associated with dispensing

Prescribing error – near misses associated with prescribing
All medicine related incidents are reported and discussed at the medicines safety group bi-monthly.
Baseline (2013/14) and first year (2014/15) data for all medicine related incidents are illustrated in
the graph below and those on the following pages.
Incidents related to medicines reported since April 2013 broken down by month
As predicated there has been an increase in reporting of medicines related incidents since the
introduction of the medicines safety team.Drug Errors since April 2013 broken down by month
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Dispensing Errors since April 2013 broken down by month
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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Prescribing Errors since April 2013 broken down by month
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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Venous Thromboembolism (VTE) Audit (baseline data 2013/14)
In January 2010 NICE guidance “Venous Thromboembolism: reducing the risk” was issued. This
updated guidance specified VTE at risk patients and that patients must be assessed on admission
and again for risk of VTE and bleeding within 24 hours of admission and prophylaxis commenced
where deemed necessary.
Baseline VTE Audit data for
2013/14. For the purpose of this
audit
patients
prophylactic
prescribed
treatment
but
omitted due to a clinical reason,
refused, on leave, sent home or
self-administered
have
been
counted as compliant.
2014/15 data is currently being ratified.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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Medication Safety Thermometer
The Trust signed up to participate in the National Medication Safety Thermometer pilot in April 2014 and has continued to use it to drive medicines safety
improvements. The Medication Safety Thermometer data is provided below 2014 – May 2015.
Pt Refused
Not documented
Valid Clinical Reason
Med not available
Route not Available
Pt Absent
Other
Total number of missed doses
April
133
88
5
8
1
22
0
257
May
136
46
18
15
1
32
0
248
Jun
58
19
14
1
1
0
0
93
Jul
85
4
13
1
0
8
0
111
Aug
77
0
19
12
0
7
0
115
Sep
39
4
17
6
6
7
0
79
Oct
17
0
0
5
0
3
0
25
Nov
39
1
3
9
0
8
0
60
Dec
19
4
3
1
1
3
1
32
Jan
87
0
16
1
0
0
0
104
Feb
81
3
16
7
3
0
0
110
March
40
5
7
18
0
7
0
77
April
23
2
2
14
5
2
1
49
May
19
1
0
2
0
0
0
22
Pts
37
46
48
42
39
43
36
48
32
52
57
41
57
43
The ’Not documented’ medicines are considered as omitted doses and therefore a
medication error. We have seen a significant improvement in the number of omitted
medicines since the introduction of the Medicines Safety Thermometer.
Work is ongoing to identify if the ‘‘Med not available’ or ‘Route not available’ errors are
avoidable or not.
Improve preventative measures to reduce chemotherapy induced nausea and vomiting
In the IHI Global Trigger Tool, the definition used for harm is as follows: unintended physical injury
resulting from or contributed to by medical care that requires additional monitoring, treatment or
hospitalisation, or that results in death.
We aim to reduce chemotherapy induced nausea and vomiting (CINV), a condition which causes
particular distress to cancer patients.
We will take a pro-active approach to the early identification of high risk patients. This will allow us
to plan earlier interventions; this work-stream will be led by the medicines safety team.
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Driver Diagram for Chemotherapy Induced Nausea & Vomiting
Implement NICE allergy guidance
NICE have recently issued guidance to manage patients who are allergic to medicines and work is
currently underway in the Trust to ensure that we fully comply with this guidance.
Improve MHRA yellow card reporting
The Yellow Card Scheme is run by the MHRA and the Commission on Human Medicines (CHM), and
is used to collect information from both health professionals and the general public on suspected
side effects or Adverse Drug Reactions (ADRs) to a medicine (including vaccines, herbals and
complementary remedies). Its continued success depends on the willingness of people to report
suspected ADRs.
We plan to improve MHRA yellow card reporting at the Trust and are part of northwest regional
MHRA Yellow card group.
Improve prevention, recognition and management of the adult
deteriorating patient
The Trust aims to significantly reduce harm associated with the deteriorating patient.
This safety improvement domain consists of 3 workstreams:

Recognition and initiation of treatment for patients with sepsis

Recognition and escalation of the deteriorating patient

Recognition and treatment of patients developing acute kidney injury (AKI)
Quality targets for this domain include:

To demonstrate 95.0 % compliance with the MEWS scoring in the adult patient.

To demonstrate that 100% of patients with suspected neutropenic sepsis receive antibiotics
within 1 hour

To detect and grade all episodes of AKI
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
To implement the Cheshire and Merseyside AKI care bundle and the overarching clinical
management guidelines

To implement the AKI and Sepsis CQUINS

To formally review and report in-hospital deaths within one month of the death occurring to
the Trust Management group and to review all applicable deaths in the Trusts mortality
review meeting.
AKI CQUIN
From the 22nd of June 2015 any serum creatinine measurement requested from CCC will be graded
for AKI by the Arrowe Park laboratory and an alert sent to the Consultant in charge of the patient.
Grade 0 alerts will be automatically suppressed and not sent. Copies of the alert e-mails will also be
sent to Triage as a) a safety check in case of consultant absence for grade 2 or 3 AKI and b) as a
central repository for collecting numerator data for grade 1-3
Each month the CQUIN audit for patients admitted to CCC, will be carried out by our junior doctors,
as participation in the audit will continue to educate them about what needs to be done and
improve compliance and standards.
Sepsis CQUIN
The Sepsis CQUIN is currently covered by the 2015 sepsis/neutropenic fever pathway in which all
patients, suspected for infection, are screened by point of care lactate levels at entrance to the
pathway. The CCC escalation policy also mandates lactate levels in all patients in whom blood
cultures have been requested – this requirement is for new admissions and patients already residing
on the inpatient wards. The updated pathway with updated documentation was initiated 10th June
2015. The pathway dictates door to needle time of 1 hour. We have the pathway in place and this
covers patients with and without neutropenia. Monthly audit will review CQUINS compliance for
new admissions with suspected infection/sepsis. Door to needle time for patients suspected of
neutropenic fever is already part of our routine audit programme.
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Development and Implementation of a Radiotherapy Safety Thermometer
The NHS Safety Thermometers allow teams to measure ‘harm’ and the proportion of patients that
are ‘harm free’ during their working day. At CCC we use the Classic NHS Safety Thermometer in our
in-patient wards (including monitoring the number of days between each CCC attributable harm
event) and the Medicines Safety Thermometer, which is mainly used in ward areas and day case
chemotherapy. We are in the process of developing a bespoke Safety Thermometer for use in
radiotherapy, which is a large part of our treatment delivery to patients in our care, as this area is
not covered by the national Safety Thermometers.
Discussions have been held involving the CGM’s for Patient Safety, Medicine Safety, Radiation
Services and Radiotherapy Manager to determine areas to be considered for Radiotherapy Safety
Thermometer initiative. Interrogating Q-Pulse for Radiotherapy incidents has shown that very few
incidents result in actual patient harm. During 2014 there were no severe or moderate harms
recorded. Of the 22 low harms: 5 related to patient falls, 12 injury to patient from equipment use, 2
communications, 3 other (no trend one off incidents). As a result the decision has been taken to
concentrate on areas relating to patient falls, and areas that have been highlighted through the
current reporting system as recurring trends relating to incorrect moves made for treatment and
omission of compensators e.g. bolus, (reported incidents 15 and 10 respectively). We will also look
at areas that can impact on patient outcome, adherence to compensation for gaps in treatment and
National target dates as these are not routinely picked up through our current incident reporting
system.
A proforma has been drafted and successfully trialled by CGM-Patient safety for ease of use and
incorporates all of the above identified areas.
A meeting was held on the 15th June 2015 with the Radiotherapy Manager and Clinical Governance
Managers for Radiation Services and Patient Safety and it was agreed that it would be of more
benefit to the department to concentrate on one specific safety aspect at a time.
The issue of incorrect or failure to apply moves during treatment is recognised as a repeated failure
and whilst often of no significant harm to the patient, is an area that improvement could be
measured. It was felt that it is feasible to apply a statement of a snap shot % harm free care
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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according to the departmental policy. Also, the data collected would be used to form the basis of a
focus group to identify an action plan to drive improvement. If the model is successful it could be
rolled out to other areas that are identified through the incident reporting system as requiring
attention. The Clinical Governance Manager for Patient Safety is to amend the proforma and it will
be presented to the departmental staff by the CGM-Radiation Services at a future Band7 meeting. It
is anticipated that the Band 7 Radiographers will be tasked with collating the data thereby taking
ownership of the project.
Fall harms data for in-patients is collected in the Classic Safety Thermometer and initially felt to be
appropriate to survey in the Radiotherapy Safety Thermometer trial, however, due to the very low
numbers of patient falls in Radiotherapy snapshot collection is unlikely to produce any worthy data.
Incidents are reported through the already established reporting system so rather than address it in
snapshot terms it was decided that this will be subject to deeper investigation when incidents occur.
At departmental level the need to introduce a falls assessment for patients attending for out-patient
treatment is recognised and work is underway to address this.
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
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Safety Improvement Plan – overview (90 day cycle) to 30th September
2015
Domain
Action
Responsible
Achieved by
(date)
Reported to or
monitored by
Patient Safety
Culture and
Leadership
Awareness of
updated Safety
Improvement
Plan (SIP) to CCC
Staff
Clinical
Governance
Manager –
Patient Safety
(CGM -PS) & CCC
Communications
Team
end July
2015
Sign Up to
Safety Lead
Patient and
Public
Involvement
Engagement of
Patients and
public in
updated SIP
Patient
Experience
Manager
End August
2015
Sign Up to
Safety Lead
Improvement
– Medicines
Safety
Audit for
chemotherapy
induced nausea
and vomiting
CGM-Medicines
Safety and
Medicines Safety
Pharmacist
End July
2015
Clinical
Governance
Manager –
Medicines
Safety (CGMMeds) & Sign
Up to Safety
Lead
Improvement
– Medicines
Safety
Review antiemetics
formulary
Medicines Safety
Team
End
September
2015
Clinical
Governance
Manager –
Medicines
Safety (CGMMeds) & Sign
Up to Safety
Lead
Improvement
– Adult
deteriorating
patient
Establish CQUIN
Audits
Acute Oncology
Site Reference
Group (SRG)
End
September
2015
Sign Up to
Safety Lead
Improvement
- Radiotherapy
Safety
Thermometer
Amend and trial
Radiotherapy
Safety
Thermometer
CGM-PS
End
September
2015
Sign Up to
Safety Lead
The Clatterbridge Cancer Centre Safety Improvement Plan updated June 2015
Complete
(date)
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