St Giles Hospice Quality Account 2018/2019 St Giles Hospice 2018-19 Quality Account | Page 13

undertake four national audits
during the year - Self-Assessment
Audit for the Controlled Drug
Accountable Officer (CDAO),
Controlled Drugs, General
Medicines and Medical Gases.
The audit tools have been
developed by Hospice UK.
The outcome of the audits are
reported back to the Medicines
Management Committee with
recommendations and action
plans to resolve areas of any
non-compliance or inconsistency.
Actions from this year included:
• I  mproved signage to remind
nurses when amending any
corrections to the CD register
• A
 greeing review and
documentation of our stock
levels with pharmacy
• I  mproved information for
patients regarding medication
use, benefits, potential harm
and any off-license use
supported by improvements in
documenting these discussions
• E
 nsuring different strengths
of the same drug are stored in
a manner which minimise risk
and ensuring this is monitored
regularly.
In 2019 we launched our Hospice
Medicines Formulary which
supports consistent practice
based on best available evidence.
The hospice employs a Specialist
Palliative Care Pharmacist to
support best practice and ensure
robust patient safety.
6.5 Patient Safety
Benchmarking
and medication errors with other
hospices both regionally and
nationally. No variations that
might give cause for concern
were identified in year.
In total during 2018/2019, 453
patient safety incidents were
reported all but one resulted in
no or minor harm to patients.
This shows that our staff are
confident and willing to report
events related to patient safety.
6.6 Tissue Viability
The hospice introduced a Tissue
Viability Nurse in 2018/19. In year
she has reviewed and revised our
policies and processes to bring
them in line with new national
guidance and to support both our
staff and care in practice.
The hospice compares its data
concerning occupancy, falls,
pressure ulcers, infection rates
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