Cardiff and Vale University Health Board

Action Taken (AI summary) • A revised escalation and referral protocol has been implemented within the Cardiac Device Clinic. • A mandatory referral trigger is now in place if a device has lost a twofold safety margin, documented in the "Managing the Unwell Patient Standard Operating Procedure". • The Standard Operating Procedure has been shared with all Physiologists and will be presented at the departmental Quality and Safety meeting on the 13th of May.

Action Taken (AI summary) The Health Board is expanding falls prevention training, undertaking improvement work regarding bedrails and auditing their use, updating the enhanced supervision framework and developing a new policy, and piloting education programmes for staff.

Action Taken (AI summary) Cardiff and Vale University Health Board has made changes to the alarm system, such as making the alarm louder and ensuring a yellow ribbon appears at the top of the monitoring screen, and is implementing a workstream to replace bedside monitors and assess/evaluate configurations across all patient monitoring.

Action Taken (AI summary) The Department of Health and Social Care outlines national measures to improve urgent and emergency care, including funding increases for ambulance trusts, hospital beds, and discharge support. It also notes improved Category 2 ambulance response times nationally and in the NWAS region, and decreased patient handover times. Swansea Bay University Health Board has developed a Standard Operating Procedure for transferring individuals with mental/physical health needs into their care. They have also improved the service level agreement with a local GP practice, recruited additional GPs and implemented changes to the night shift pattern to alleviate staff workload. HMPPS has received assurance from the Governing Governor at HMP Cardiff that all staff are aware of emergency medical codes via the radio system. The Governor is also committed to encouraging staff to raise concerns about an individual's management and will discuss with the Head of Healthcare how healthcare staff can be empowered to do so.

Action Taken (AI summary) Cardiff and Vale UHB has updated the eCORFLO booklet to include reference to sepsis and will provide an additional information sheet for early warning signs of sepsis. They will also provide adult and paediatric symptom cards to patients and parents and advise other Welsh health boards of these actions. Cardiff and Vale UHB updated patient information for new PEG patients to include sepsis signs (updated Jan 30, provided from Feb 6). The ANA team will ensure new patients receive this info by March 1. Cardiff and Vale UHB also ordered Adult and Paediatric Symptom Cards to give to patients with infection signs, with the ANA team distributing them by March 1.

Action Taken (AI summary) The practice has taken on a full-time Clinical Pharmacist to oversee repeat and acute prescribing, and patient monitoring. They achieved an NHS award for quality improvement in this area. The University Health Board conducted an internal review and will remind staff of the importance of full and diligent information taking. The matter of medication reviews has been raised with the Primary Community and Intermediate Care Clinical Board as a practice issue.

Action Taken (AI summary) The University Health Board has discontinued the practice of inserting chest drains at a 'marked' point and has purchased equipment. A task and finish group will oversee implementation and assessment across the Health Board and will report to the Quality, Safety and Experience Committee.

Action Taken (AI summary) The University Health Board has reviewed systems for ECG storage, reinforced the use of the MUSE system, and implemented training on intravenous infusion labelling. The learnings from this incident will be shared, and the Regulation 28 report will be shared with all Clinical Boards.