Burton Hospitals NHS Foundation Trust. On: 25 January Review Date: December Corporate / Directorate. Department Responsible for Review:
|
|
- Christian Stanley
- 5 years ago
- Views:
Transcription
1 POLICY DOCUMENT Burton Hospitals NHS Foundation Trust MEDICAL DEVICES TRAINING POLICY Approved by: Trust Executive Committee On: 25 January 2017 Review Date: December 2019 Corporate / Directorate Clinical / Non Clinical Department Responsible for Review: Distribution: Essential Reading for: Corporate Non Clinical Medical Director All Clinical Staff Information for: Learning & Development Policy Number: Version Number: 78 7 Signature: Date: Chief Executive
2 Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Medical Devices Training Policy Original Issue Date: September 2006 Date of Last Review: June 2015 Reason for amendment: Update Responsibility: Stored: Medical Director Intranet site Linked Trust Policies: Risk Management Policy Medical Devices Policy Learning and Development Policy Induction Policy Policy for the Reporting and Management of Adverse Incidents and Near Misses Managing Performance and Supporting Staff E & D Impact assessed EIA 136 Consulted Corporate Nursing Divisional Nurse Directors Equipment Library Learning & Development Manager Medical Director Medical Electronics Lead of Allied Healthcare professional.
3 REVIEW AND AMENDMENTS LOG Version Type of Change Date Description of Change 7 Amendment to Appendix F July 2015 Removal of Competence must be assessed by an authorised trainer. Insertion of competence verified by Trainer/Senior Sister/Line Manager Amendment to approved by November2016 Trust Executive committee Review date November 2016 Review date November 2019 Amendment to Consulted November 2016 Removal Head Nurses, Insertion of Divisional Nurse Directors Amendment to Consulted November 2016 Removal of Head of Therapies, insertion of Lead Allied Health Care Professional Amendment to 5.5 November 2016 Removal of Head Nurses, insertion of Divisional Nurse Directors. Amendment to 7.2 November 2016 Removal of on the trust database, insertion of in the Medical Device Training Files Amendment to 8.5 November 2016 Removal of competent colleague, insertion of cascade trainer or trained super user. Amendment to 8.8 November 2016 Insertion of and have documentary evidence in their medical devices training file. Amendment to 9 November 2016 Insertion of Overall monitoring of compliance is the responsibility of the medical director Removal of clinical, insertion of Division Risk and Patient safety Amendment to Appendix A November 2016 Insertion of Baxter Insertion of Freego feeding pump Amendment to Definitions 5.5 November 2016 Removal of Head Nurse, insertion of Divisional Nurse Directors Addition of Appendix G November 2016 Insertion of Appendix G Insertion of Patient form
4 MEDICAL DEVICES TRAINING POLICY CONTENTS Paragraph No Subject Page No. 1 Introduction 1 2 Scope 1 2 Aims & Objectives 1 4 Definitions 2 5 Duties and Responsibilities Risk Assessment Training Needs Analysis Training and Education Monitoring Compliance Sources 8 Appendix A Non-Specialist High Risk Device List 9 Appendix B Authorised User Device Record 10 Appendix C Training Requirements Flow Chart 11 Appendix D Low Risk Staff Self-Assessment Record 12 Appendix E High/Moderate Risk Self- Assessment Record 13 Appendix F Generic Competency Document 14 Appendix G End-User Agreement 15
5 Burton Hospitals NHS Foundation Trust MEDICAL DEVICES TRAINING POLICY 1. INTRODUCTION The use of medical devices within the clinical areas plays an ever increasing role in the assessment, management and evaluation of patient care. There is well established evidence that a significant number of adverse patient events relate to the use or misuse of medical devices, it is therefore important that the appropriate staff are trained to operate such equipment safely. 2. SCOPE 2.1 Training in the use of therapeutic and diagnostic medical devices applies to all bands and disciplines of clinical and scientific staff operating such devices within their role. 2.2 This policy applies to all clinical and scientific departments. 3. AIMS AND OBJECTIVES The aims of this policy is to ensure the Trust meets the requirements and guidance issued by the various bodies e.g. The Medicines and Healthcare products Regulatory Agency (MHRA), NHS Litigation Authority Risk Management Standards (NHSLA), Care Quality Commission (CQC) and The Health and Safety Executive (HSE) related to training. This policy will provide a framework for the identification, provision and recording of medical device training. This policy will: Provide a clear framework for training requirement and the safe use of medical devices. Ensure that a consistent approach to training is in place across all disciplines throughout the Trust. Define the minimum standards required for any training in the safe use of medical devices, based on a risk scoring system. Provide a list of non-specialist high risk equipment (Appendix A). 1
6 4. DEFINITIONS 4.1 The EU Directive for the registration of medical devices defines a medical device as: any instrument, apparatus, appliance, material or other article, whether used alone or in combination, including the software necessary for its proper application intended by the manufacturer to be used for human beings for the purpose of: Diagnosis, prevention, monitoring, treatment or alleviation of disease, Diagnosis, monitoring, treatment, alleviation of or compensation for an injury or handicap, Investigation, replacement or modification of the anatomy or of a physiological process, Control of conception, and which does not achieve its principal intended action in or on the human body by pharmacological, immunological or metabolic means, but which may be assisted in its function by such means 4.2 In day to day use the terms medical device and equipment are often interchangeable. This policy applies primarily to re-usable electro-mechanical medical equipment. 4.3 Please refer to the Trust s Medical Devices Policy for further detail on the classification and management of medical devices. 5. DUTIES AND RESPONSIBILITIES 5.1 All Staff/User of Medical Devices Are responsible for: ensuring they are trained and competent in the use of any medical device within the requirements of their position. maintaining personal records to verify their training status. acting in accordance with professional codes of conduct, including not operating equipment on which they have not received training or skills updates, or do not feel competent. ensuring that they attend any equipment training sessions their line manager has arranged for them. 5.2 All Line Managers Are responsible for: ensuring that the departmental equipment training records are updated on a monthly basis 2
7 ensuring that staff are released from their duties when required to attend training informing the Medical Engineering Department if there are any local device list changes so that the central inventory can be updated accordingly ensuring that all devices are used according to manufacturer s guidelines providing an up to date inventory of user manuals for staff to access reviewing medical device training needs as part of the appraisal process escalating any medical device training issues via the Trust governance procedures ensuring all equipment is decontaminated and returned to Medical Equipment Library after use as appropriate 5.3 Medical Equipment Officer Is responsible for: co-ordinating medical device training producing audits and reports for senior clinical staff on medical equipment training performance advising line managers on any medical device training issues to assist Heads of Department and Line Managers to risk score medical devices ensuring that all devices have been appropriately risk scored 5.4 Clinical specialists/practice Development Are responsible for: cascading their expert knowledge to device users according to their particular specialist field 5.5 Chief Nurse / Chief Operating Officer / Divisional Nurse Directors and Heads of Department Are responsible for: ensuring that all staff are aware of their responsibilities according to this policy taking appropriate action in the event of non-compliance with this policy ensuring that all devices have been appropriately risk scored 5.6 Medical Director Is responsible for: the overall implementation and monitoring of compliance with this policy 6. RISK ASSESSMENT 6.1 In line with the Trust Risk Management policy all medical devices will be assigned a risk score using the Trust risk assessment matrix. This inherent risk score will be 3
8 used to determine the level of training required and the frequency of updates for each device. For the purposes of risk assessing medical devices, the Low risk score and Moderate risk score of the Trust s risk matrix have been combined to Low Risk 6.2 The risk scores generated will determine which category each device falls into: Risk Matrix Category Device Risk Category High Risk High Risk Score Score Significant Risk Moderate Risk Score 8-12 Score 8-12 Moderate Risk Score 4-6 Low Risk Low risk Score 1-6 Score 1-3 Low Risk (Score 1-6) - Devices whose failure or misuse is unlikely to result in serious consequences. Moderate risk (Score 8-12) - Devices whose failure or misuse would have a significant impact upon patient care or temporary adverse health consequences, but would be unlikely to cause direct serious harm High risk (15-25) - Devices that have the potential to cause serious adverse consequences or death should they fail or be misused. Devices recently associated with serious harm. 6.3 All risk scores will be subject to an annual review or may be reviewed following a clinical incident or MHRA alert by the Medical Equipment Officer. 7. TRAINING NEEDS ANALYSIS 7.1 Equipment Inventory The Medical Engineering Department hold a full inventory of all diagnostic and therapeutic equipment. Departmental Managers will be responsible for maintaining a local equipment inventory will be linked to a centrally based medical equipment database. Inventories will highlight which risk category each device falls into and 4
9 must be reviewed and updated by Departmental Managers in conjunction with Medical Engineering on a six monthly basis or if any new equipment enters the department. 7.2 Authorised Users On local induction each member of staff will have their training recorded. Line managers must then decide and record in medical device training files, which medical devices it will be necessary for that staff member to use within their role. Staff should keep a copy of their authorised devices using the form in Appendix B. For Moderate and High risk devices staff should be made aware that until evidence of competence has been produced they should not be used unsupervised. 7.3 Annual Review As part of the annual appraisal process line managers will review medical equipment training needs prioritising high risk devices. 8. TRAINING AND EDUCATION 8.1 Training Requirements Departmental Managers will use the flow chart found in Appendix C to determine what level of training and frequency of updates is required for each device, however, the line manager or staff member may at any time decide that additional training is required. Advice and support on how to access the required training is available from the Medical Equipment Officer, Practice Development Team, Learning and Development and Specialist Nursing teams i.e. Outreach, Palliative Care. 8.2 Low Risk Devices Self-assessments can be used for low risk devices or for staff that have successfully completed previous competency assessments and have continued to maintain that level of competency by continued regular use of the device. The self-assessment form found in Appendix D can be used for this on induction. Once this has been completed unless there is a device update, clinical incident or change in practice no further evidence would be required. 8.3 Moderate Risk Devices All moderate risk devices require initial formal/informal training followed by competency assessment, then dependant on the frequency of use, staff may selfassess as competent on a yearly basis. The form in Appendix E should be used for this and countersigned by the line manager. Formal/informal training and 5
10 competency assessment should always be completed if there is a software update, clinical incident or change in practice. 8.4 High Risk Devices All high risk devices require update training and competency assessment using Trust competency documents (Appendix F) on a minimum 3 yearly basis. Some manufacturers provide competency based user training and will supply competency documents. These are acceptable as long as they do not, nor subsequently allow a user to, contradict a Trust standard configuration or usage. A list of non-specialist high risk equipment can be found in Appendix A. This is not designed to be an exhaustive list of high risk equipment across the Trust it is recognised that there are other high risk devices in use in specialist areas. The Trust aims to have all of its authorised users of high risk devices evidenced as competent in their use. Any failure to comply with this will be escalated to the Head of Department and subsequently to the Medical Devices User Group and Director of Nursing via the Medical Equipment Officer for an action plan to be formulated. 8.5 Competency Competency can be established in a number of ways: Formal Training Classroom based training In-House Training Department based training either by a designated trainer, cascade trainer or trained super user. External Training Training via an accredited course For example Advanced Life support (Defibrillators) Qualifications If the user holds a qualification which includes instruction in a devices then the user would be competent whist they maintain that qualification Manufacturer Device manufacturer will often provide training on request and may train trainers to cascade the training to other users Clinical Specialists Other staff member who have knowledge of a specific device may train others in its use Healthcare professionals who as part of their professional qualifications gained competence to use particular devices and have continued on a daily basis to use such devices may self-assess their own competence on low, moderate and some high risk devices using the competency statement in Appendix F. The form in Appendix E should be used to record this and countersigned by the line manager. However, it may be necessary for a formal update to take place in circumstances such as software updates, clinical incidents, new devices, changes in practice or should the line manager deem it necessary. 6
11 8.7 Delegated Duties This policy is primarily aimed at registered healthcare professionals, however, it is recognised that the use of medical devices and equipment may be delegated to a Health Care Assistant or other associated support staff, but the registered professional remains accountable at all times for ensuring the competence of individuals and that delegation is appropriate and safe. 8.8 Training of Bank, Agency or Locum staff If Bank, agency and /or locum staff are required and authorised to use equipment, then equipment training will be provided as part of their induction. Each department employing temporary staff must ensure that they are competent to use relevant equipment and have documentary evidence in their medical devices training file.. In the case of short term or short notice employment it may be necessary to limit the use of certain devices if competency cannot be determined. The ward/department manager (or their deputy) must inform the individual of equipment that they are authorised to use and any exceptions. 8.9 Non-Attendance Any member of staff not attending pre-arranged equipment training will have this documented by the trainer and escalated to their line manager. Should a particular member of staff persistently not attend this may result in their access to medical devices being restricted and their performance being reviewed by their line manager End-User Training As part of effective clinical management and improving outcomes some patients may continue their therapeutic intervention using Trust owned devices in a location other than Burton Hospital. In this case the patient, carer or family member must be trained in the use of such devices. It is the responsibility of the healthcare professional discharging the patient with the medical device to ensure that a suitably qualified person has carried out training appropriate to the individual patient, carer or family member. Written instruction will be provided along with contact numbers where help and advice can be sought particularly in an emergency. The form in Appendix G will be completed and retained in the patients notes. 9. MONITORING COMPLIANCE Monitoring of the Trust s staff and their competency in the use of medical equipment that their individual role requires of them, is an essential element of the governance 7
12 arrangements within the Trust. Overall monitoring of compliance is the responsibility of the Medical Director The Medical Equipment Officer will produce a quarterly medical device training audit report which will be reviewed by both the Head Nurses and the Medical Equipment User Group. Regular review of related adverse incident reports will be undertaken by the Divisional Risk and Patient Safety Manager. Trends and patterns may emerge to indicate success or failings of the training strategy, highlighting areas which require focused attention. 10. SOURCES Devices in Practice A Guide for Health and Social Care Professionals MHRA The Medical Devices Regulations SI 2002/618. Information. London: Office of Public Sector Medicines Healthcare Regulatory Agency. (2008). MDA2008/001 Reporting Adverse Incidents and Disseminating Medical Device Alerts. Medicines Healthcare Regulatory Agency (MHRA). Medicines Healthcare Regulatory Agency. (2006). DB 2006(05) Managing Medical Devices. Medicines Healthcare Regulatory Agency (MHRA). Directive 2007/47/ec of the European Parliament and of the council of 5 September, 2007, which amended the Council Directive 93/42/EEC of 14 June,
13 Appendix A Non-Specialist High Risk Equipment List Baxter olumetric Infusion Pumps yringe Drivers Automated External Defibrillators (AED) Suction Units (wall mounted and portable) Patient Controlled Analgesia Pumps (PCA s) Oxygen Flowmeters Humidification Devices Nebulisers Freego feeding pump 9
14 Staff Authorised Devices Record Appendix B Name Department Personal Number Date Device Name Device Model Competent Y/N Evidence Provided Review Date I understand that the above is the list of devices that I have been authorised to use and I am professionally accountable for maintaining my own competency Staff.. Line Manager 10
15 Appendix C Medical Devices Training Flow Chart OR OR 11
16 Appendix D Low Risk Device Self-Assessment Record Name Personal Number Department Role/Designation Device Name/Model Initial Training Given By Date Competent Yes/No The above is a list of the low risk devices that I use as a part of my normal working duties. Where I have self-assessed as competent in their use I understand that is is my professional responsibility to maintain this competence and I may be asked to demonstrate my knowledge at any time. Where I have self-assessed as not competent I will inform my line manager and complete appropriate training as soon as possible. Signed. 12
17 Appendix E High/Moderate Risk Device Self-Assessment Record Name Personal Number Department Role/Designation Device Name/Model Initial Training Given By Date Volumetric Infusion pumps Syringe drivers Automated External Defibrillators (AED) Suction Units (wall mounted and portable) Patient Controlled Analgesia Pumps (PCA) Oxygen Flowmeters Humidification Devices Nebulisers Competent Yes/No The above is a list of the high/moderate risk devices that I use as a part of my normal working duties. Where I have self-assessed as competent in their use using the competency document in Appendix F of the Medical Devices Training Policy I understand that is is my professional responsibility to maintain this competence. I may be asked to demonstrate my knowledge at any time. Where I have self-assessed as not competent I will inform my line manager and complete relevant training as soon as possible. Signed. Date I certify that the staff named has the appropriate skills and knowledge to self-assess for the above high-moderate risk devices and I agree with their assessment. Line Manager Name.. Signature. Date 13
18 Generic Medical Device Competency Statement Appendix F Verified Assessment: Device Name and Model Name: Personal Number: Job Title/Designation: Ward/Department: Verification of Competence is undertaken by assessment against the following criteria: These statements are designed to indicate competence to use this device, however, responsibility for its use remains with the user. If you are in any doubt as to your level of competence for this device please complete any relevant education to improve your skills. This can be from a variety of sources i.e. self-directed, e-learning, taught course etc. The Learner must be able to safely and competently demonstrate: Achieved Independently Date Achieved Pre-operational inspection and correct set-up of device: 1. How to be sure that this is the most appropriate device for the intended use? 2. How to check for damage, wear and faults? 3. How to switch the device on? 4. Which are the correct consumables/accessories for this device? 5. Is the device within its service date? Ability to operate the device safely: 6. How to check that the device is working? 7. How to use all available functions of the device? 8. Are there any limitations/contraindication for the use of this device? 9. Know what default settings may be present on this device and how to change them if necessary? 10. How to check the progress/operation of the device? 11. What factors may affect safe operation or accuracy of this device? Troubleshooting and Maintenance: 12. How to recognise device alerts/alarms and rectify safely? 13. Know what action to take if there is an error or failure of this device? 14. How to clean/decontaminate this device? How and where the device should be stored safely? Statement: I have demonstrated competence and knowledge relevant to this device and I am aware of my professional responsibilities for continuing professional development. I am competent to use this device with no further training. Signed Date. Competence Verified by Trainer/Senior Sister/Line Manager Name (Print) Signed. Designation
19 Patient End-User Agreement Form Appendix G Name. B Number. D.O.B. Name of Medical Device. Asset Number.. I have explained the use of the medical device to the patient and/or their carer I have explained the intended benefits and reasons for the use of the medical device I have explained the appropriate cleaning and storage instructions I have explained the pre-use checks I have explained what device alerts and alarms may occur I have explained where to get further advice and given appropriate contact numbers I have given appropriate written instructions on the use of this device I confirm that I have given the patient and/or carer all of the above information and that they have no further questions regarding its use Name.. Signed Designation/Role Date... Statement of Patient/Carer I understand how to use this medical device and where to get further information should I require it. Name. Signed Date Relationship to patient (if applicable)... 15
Elmarie Swanepoel 24 th September 2017
MEDICAL EQUIPMENT TRAINING POLICY Policy Register No: 10010 Status: Public Developed in response to: Best practice Contributes to CQC Regulation: 15 Consulted With: Post/Committee/Group: Date: Medical
More informationVersion Date Author Reason. 1-3 Sept May July 2014 R Turner & M. 6 September 2017
TRUST POLICY AND PROCEDURE FOR THE COMPETENCY AND TRAINING REQUIREMENTS CONNECTED WITH MEDICAL DEVICES Reference Number: POL-RKM/1221/2006 Old ref no. RKM 2008 011 Version: 6 Status: Final Author: Mark
More informationConsulted With Individual/Body Date Medical Devices Group August 2014
Medical Equipment Policy - Safe Use Of Medical Equipment Developed in response to: Contributes to Care Quality Commission Regulation Policy Registration No. 04066 Status: Public MHRA Guidance Regulation
More informationVersion Number: 004 Controlled Document Sponsor: Controlled Document Lead:
Chief Investigators and Principal Investigators in Research Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Policy Governance To set out the responsibilities of
More informationBurton Hospitals NHS Foundation Trust. On: 30 January Review Date: November Corporate / Directorate. Department Responsible for Review:
POLICY DOCUMENT Burton Hospitals NHS Foundation Trust MANAGEMENT OF EXTERNAL AGENCY VISITS, INSPECTIONS, ACCREDITATION AND RESULTING RECOMMENDATIONS Approved by: Trust Executive Committee On: 30 January
More informationCentral Alerting System (CAS) Policy
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified By Central Alerting System (CAS) Policy NTW(O)17 Gary O Hare Executive Director of Nursing and Operations Tony Gray
More informationDissemination of Alerts within the Trust for Reusable Medical Devices
Standard Operating Procedure 12 (SOP 12) Dissemination of Alerts within the Trust for Reusable Medical Devices Why we have a procedure? This procedure sets out the steps to be followed to ensure that a
More informationMedical Devices Management Policy
Document Author Written By: Medical Devices Co-ordinator Date: 07/02/17 Lead Director: Exectuve Director of Nursing & Quality Authorised Authorised By: Chief Executive Date: 11/04/2017 Effective Date:
More informationMedical Devices Policy
Medical Devices Policy Reference No: Version: 8 P-CS-09 Ratified by: LCHS Trust Board Date ratified: 12 th September 2017 Name of originator/author: Medical Devices Committee Name of approving committee/responsible
More informationVersion Number: 003. On: September 2017 Review Date: September 2020 Distribution: Essential Reading for: Information for: Page 1 of 13
CONTROLLED DOCUMENT Reporting Research Incidents and Breaches Policy CATEGORY: CLASSIFICATION: PURPOSE Controlled Number: Document Policy Governance To set out the framework and principles for reporting
More informationHoist and Sling for Safer Patient Use Policy
Hoist and Sling for Safer Patient Use Policy DOCUMENT CONTROL: Version: 4 Ratified by: Quality and Safety Sub Committee Date ratified: 30 January 2017 Name of originator/author: Back Care Advisor Name
More informationMedical Devices Policy
Medical Devices Policy Who Should Read This Policy Target Audience All Clinical Staff Version 1.0 December 2015 Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process 5 4.1 5.0
More informationSUP 08 Operational procedures for Medical Gas Pipeline Systems (MGPS) Unified procedures for use within NHS Scotland
SUP 08 Operational procedures for Medical Gas Pipeline Systems (MGPS) Unified procedures for use within NHS Scotland May 2015 Contents Page Acknowledgements... 4 Introduction... 5 1. Aim and scope... 6
More informationPolicy for the Reporting and Management of Incidents Including Serious Incidents. Version Number: 006
CONTROLLED DOCUMENT Policy for the Reporting and Management of Incidents Including Serious Incidents CATEGORY: CLASSIFICATION: PURPOSE Controlled Number: Document Policy Governance To set out the principles
More informationDate 4 th September 2015 Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate Director of Quality Laura Rowe, Compliance Manager
TB 099/15 Meeting title Report title Trust Board Risk Management Strategy Date 4 th September 2015 Lead director Report author FOI status Dr Ruth Charlton, Joint Medical Director / Jill Down, Associate
More informationDecontamination of Medical and Laboratory Equipment Prior to Maintenance or Transportation
Decontamination of Medical and Laboratory Equipment Prior to Maintenance or Transportation Version 4.0 Date to be reviewed January 2020 To be reviewed by Medical Engineering Manager Policy Title: Decontamination
More informationMEDICINES FOR HUMAN USE (CLINICAL TRIALS) REGULATIONS Memorandum of understanding between MHRA, COREC and GTAC
MEDICINES FOR HUMAN USE (CLINICAL TRIALS) REGULATIONS 2004 Memorandum of understanding between MHRA, COREC and GTAC 1. Purpose and scope 1.1 Regulation 27A of the Medicines for Human Use (Clinical Trials)
More informationPolicy for Critical Care Training and Education
Policy for Critical Care Training and Education 1 Policy Title: Executive Summary: Critical Care Policy for Training and Education This policy provides guidance for the management of learning and development
More informationNON-MEDICAL PRESCRIBING POLICY
NON-MEDICAL PRESCRIBING POLICY To be read in conjunction with the Medicines Policy, Controlled Drug Policy and the FP10 Prescribing Forms Policy Version: 5 Date of issue: August 2017 Review date: August
More informationJob Description. Home based to cover South East England and London
Job Description Job Title: Job Ranking: Responsible to: Location: Senior Mobility ngineer N/A Lead Mobility ngineer Home based to cover South ast ngland and London Hours Per Week: 37.5 Date: January 2014
More informationPatient Weighing Scales Policy
Patient Weighing Scales Policy Policy Title: Executive Summary: Patient Weighing Scales Policy East Cheshire NHS Trust is committed to the health safety and welfare of all of the patients it treats. The
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Decontamination of Healthcare Equipment following Patient Use and Prior to Service or Repair
The Newcastle upon Tyne Hospitals NHS Foundation Trust Decontamination of Healthcare Equipment following Patient Use and Prior to Service or Repair Version No.: 5.0 Effective From: 27 December 2017 Expiry
More informationTo describe the process for the management of an infusion pump involved in an adverse event or close call.
TITLE INFUSION PUMPS FOR MEDICATION & PARENTERAL FLUID ADMINISTRATION SCOPE Provincial, Clinical DOCUMENT # PS-70-01 APPROVAL LEVEL Executive Leadership Team SPONSOR Provincial Medication Management Committee
More informationAppendix 1 MORTALITY GOVERNANCE POLICY
Appendix 1 MORTALITY GOVERNANCE POLICY 1 Policy Title: Executive Summary: Mortality Governance Policy For many people death under the care of the NHS is an inevitable outcome and they experience excellent
More informationPOLICY ON THE IMPLEMENTATION OF NICE GUID ANCE
POLICY ON THE IMPLEMENTATION OF NICE GUID ANCE Document Type Corporate Policy Unique Identifier CO-019 Document Purpose To outline the process for the implementation and compliance with NICE guidance and
More informationResearch Governance Framework 2 nd Edition, Medicine for Human Use (Clinical Trial) Regulations 2004
Title: Outcome Statement: Research Auditing and Monitoring Procedures Researchers in the Trust and research partners will be informed about the requirements and procedures involved in research audit and
More informationCentral Alert System (CAS) RISK MANAGEMENT POLICY /PROCEDURE: CENTRAL ALERT SYSTEM (CAS)
Central Alert System (CAS) 15.08 SECTION: 15 - RISK MANAGEMENT POLICY /PROCEDURE: 15.08 NATURE AND SCOPE: SUBJECT: POLICY- TRUST WIDE CENTRAL ALERT SYSTEM (CAS) The Central Alert System (CAS) (formally
More informationMedical Devices Management Policy
Medical Devices Management Policy Document Reference Document Status POL025 Version: V2.0 Approved DOCUMENT CHANGE HISTORY Initiated by Date Author (s) 20 May 2015 Richard Kirk Version Date Comments (i.e.
More informationJOB DESCRIPTION. Debbie Grey, Assistant Director, ESCAN
JOB DESCRIPTION Job Title: Division/Department: Responsible to: Paediatric Occupational Therapist Community Services Ealing Ealing Paediatric Occupational Therapy Service Professional and Clinical to Band
More informationRemoval of Annual Declaration and new Triennial Review Form. Originated / Modified By: Professional Development and Education Team
Review Circulation Application Ratificatio n Author Minor Amendment Supersedes Title DOCUMENT CONTROL PAGE Title: Mentorship in Nursing and Midwifery Policy Version: 14.1 Reference Number: Supersedes:.14.0
More informationManagement of Reported Medication Errors Policy
Management of Reported Medication Errors Policy Approved By: Policy & Guideline Committee Date of Original 6 October 2008 Approval: Trust Reference: B45/2008 Version: 4 Supersedes: 3 February 2015 Trust
More informationDate ratified November Review Date November This Policy supersedes the following document which must now be destroyed:
Document Title Reference Number Lead Officer Author(s) (name and designation) Ratified by Cleaning Policy NTW(O)71 James Duncan Deputy Chief Executive / Executive Director of Finance Steve Blackburn Deputy
More informationJOB DESCRIPTION. Deputy Director of Nursing - Tissue Viability. Director of Nursing. Tissue Viability Support Tissue Viability Nurse
JOB DESCRIPTION Job Title: Reporting to (title): Tissue Viability Nurse Specialist Deputy Director of Nursing - Tissue Viability Professionally Accountable to (title): Responsible for Supervising (if appropriate):
More informationClinical Lead. Contract of Employment
JOB DESCRIPTION AND PERSON SPECIFICATION FOR Clinical Lead AGENDA FOR CHANGE BAND Band 7 HOURS AND DURATION As specified in the job advertisement and the Contract of Employment AGENDA FOR CHANGE REF NO
More informationTrust Policy and Procedure Document Ref. No: PP (17) 283. Central Alerting System (CAS) Policy and Procedure. For use in: For use by: For use for:
Trust Policy and Procedure Document Ref. No: PP (17) 283 Central Alerting System (CAS) Policy and Procedure For use in: For use by: For use for: Document owner: Status: All areas of the Trust including
More informationThe Newcastle upon Tyne Hospitals NHS Foundation Trust. Central Alert System (CAS) Policy and Procedure
The Newcastle upon Tyne Hospitals NHS Foundation Trust Central Alert System (CAS) Policy and Procedure Version No.: 4.1 Effective From: 6 August 2013 Expiry Date: 6 August 2016 Date Ratified: 2 August
More informationLone worker policy. Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead
Document level: Trustwide (TW) Code: GR33 Issue number: 3 Lone worker policy Lead executive Director of Nursing Therapies Patient Partnership Author and contact number Safety and Security Lead 01244 397618
More informationDIAGNOSTIC CLINICAL TESTS AND SCREENING PROCEDURES MANAGEMENT POLICY
DIAGNOSTIC CLINICAL TESTS AND SCREENING PROCEDURES MANAGEMENT POLICY (To be read in conjunction with Diagnostic Imaging Requesting and Interpreting Radiographs by Non Medical Practitioners Policy, Consent
More informationResearch Staff Training
REFERENCE: VERSION NUMBER: 3.0 EFFECTIVE DATE: 28-03-18 REVIEW DATE: 28-03-20 AUTHOR: Research Infrastructure Manager REVIEWED BY: Research & Innovation Group APPROVED BY: Deputy Director of Research CONTROLLER:
More informationBlood Transfusion Policy. Version Number: 6.1 Controlled Document Sponsor: Controlled Document Lead: On: December 2014.
Blood Transfusion Policy CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Policy Clinical The policy describes the framework and principles required to deliver best transfusion
More informationGuidance on Quality Management in Laboratories
Guidance on Quality Management in Laboratories series QULAITY IBMS 1 Institute of Biomedical Science Guidance on Quality Management in Laboratories As the UK professional body for biomedical science the
More informationHealth Care Department Registers and Licences Bureau; Emergency Medical Care Bureau; Bureau of Occupational Health; Poison Information Centre. 2
Health Board Irma Nool 03.06.2010 Health Care Department Registers and Licences Bureau; Emergency Medical Care Bureau; Bureau of Occupational Health; Poison Information Centre. 2 The Area of Emergency
More informationand decision making. Initially for a period of three years, then on a rolling contract subject to a notice period of six calendar months.
Post Holder: Contracting Organisation: Job Title: Responsible to: Professionally accountable to: Hours: Duration: Remuneration: Expenses: Status: Dr Philip Anthony Dobson The Designated Body Responsible
More informationBest Practice Guidelines - BPG 9 Managing Medicines in Care Homes
Best Practice Guidelines - BPG 9 Managing Medicines in Care Homes Medicines in Care Homes 1 DOCUMENT STATUS: Approved DATE ISSUED: 10 th November 2015 DATE TO BE REVIEWED: 10 th November 2017 AMENDMENT
More informationPOLICY ON LONE WORKING JANUARY 2012
POLICY ON LONE WORKING JANUARY 2012 Author: Sheena Gordon V&A Co-ordinator Responsible Director: Ian Reid Director of HR Approved by: Health and Safety Forum Date for Review: January 2014 Version: 2.0
More informationContract of Employment
JOB DESCRIPTION AND PERSON SPECIFICATION FOR Deputy Sister / Deputy Charge Nurse AGENDA FOR CHANGE BAND Band 6 HOURS AND DURATION As specified in the job advertisement and the Contract of Employment AGENDA
More informationThis controlled document shall not be copied in part or whole without the express permission of the author or the author s representative.
This document is also available in large print and other formats and languages, upon request. Please call NHS Grampian Corporate Communications on (01224) 551116 or (01224) 552245. This controlled document
More informationTo establish a consistent process for the activity of an independent double-check prior to medication administration, where appropriate.
TITLE INDEPENDENT DOUBLE-CHECK SCOPE Provincial, Clinical DOCUMENT # PS-60-01 APPROVAL LEVEL Senior Operating Officer, Pharmacy Services SPONSOR Provincial Medication Management Committee CATEGORY Patient
More informationSystmOne COMMUNITY OPERATIONAL GUIDELINES
SystmOne COMMUNITY OPERATIONAL GUIDELINES Guidelines IM&T 11 Date: August 2007 Document Management Title of document SystmOne Community Operational Guidelines Type of document Guidelines IM&T 11 Description
More informationMedical Devices Policy
Medical Devices Policy This policy describes the process for the management of medical devices. Key Words: Medical Devices, Medical Equipment Version: 6 Adopted by: Quality Assurance Committee Date adopted:
More informationSt Anne's Community Services Staff Manual
4.01 St Anne's Health and Safety Policy Title of Policy: 4.01 St. Anne s Health and Safety Policy Issue date: July 2016 Version number: V5.0 Ratified by: H&S Committee 27 th July 2016 Expiry date: July
More informationMcKinley T34 Ambulatory syringe pump Used in the provision of adult palliative and end of life care
Health Guidance McKinley T34 Ambulatory syringe pump Used in the provision of adult palliative and end of life care Publication Code: HCR-0214-083 Publication date: 26 February 2014 Page 1 of 7 Health
More informationTrial Management: Trial Master Files and Investigator Site Files
Title: Outcome Statement: Written By: Trial Management: Trial Master Files and Investigator Site Files Staff working on research studies in NSFT will be informed about the requirements of setting up and
More informationDeputise and take charge of the given area regularly in the absence of the clinical team leader who has 24 hour accountability and responsibility.
JOB DESCRIPTION AND Public Health Nurse School Nurse PERSON SPECIFICATION FOR: AGENDA FOR CHANGE BAND: Band 6 HOURS AND DURATION; As specified in the job advertisement and the Contract of Employment AGENDA
More informationNHS Lanarkshire Policy for the Availability of Unlicensed Medicines
NHS Lanarkshire Policy for the Availability of Unlicensed Medicines Prepared by: NHS Lanarkshire Chief Pharmacist Endorsed by: Area Drug & Therapeutic Committee Previous Version/Date: Primary Policy Date:
More informationPOLICY DOCUMENT CONTROL PAGE
POLICY DOCUMENT CONTROL PAGE TITLE Title: MOVING AND HANDLING POLICY Version: 2. Reference Number: HSP 6 SUPERSEDES Supersedes: VERSION 1 of October 2006 Description of Amendment(s): Nil ORIGINATOR Originated
More informationHEALTH AND SAFETY POLICY
HEALTH AND SAFETY POLICY Version: 4 Ratified by: Trust Board (Required) Date ratified: January 2016 Title of originator/author: Title of responsible committee/group: Head of Corporate Business Date issued:
More informationUnless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version
Policy No: RM63 Version: 3.0 Name of Policy: Policy for the dissemination, implementation and management of safety alerts Effective From: 28/07/2017 Date Ratified 08/06/2017 Ratified SafeCare Council Review
More informationNHS Lewisham CCG Health & Safety Policy
NHS Lewisham CCG Health & Safety Policy Document Information Category: Summary: Corporate The purpose of this policy is to outline the Health and Safety strategy in accordance with statutory requirements
More informationVELINDRE NHS TRUST. Trust Procedure PROCEDURE FOR THE IMPLEMENTATION OF NATIONAL INSTITUTE OF HEALTH & CLINICAL EXCELLENCE (NICE) GUIDANCE
Clinical Excellence (NICE) Guidance VELINDRE NHS TRUST Trust Procedure Black 21 PROCEDURE FOR THE IMPLEMENTATION OF NATIONAL INSTITUTE OF HEALTH & CLINICAL EXCELLENCE (NICE) GUIDANCE Lead: Lisa Heydon-Mann
More informationElectrical Services Policy
Engineering, Maintenance & Infrastructure Electrical Services Policy EM&I C002 Version 1.0 15 th May 2015 Section Contents Page Page 1.0 Introduction... 4 2.0 Purpose... 4 3.0 Scope... 4 4.0 Management
More informationSafe Care and Support
SPECIALIST PALLIATIVE CARE May 2014 Safe Care and Support Supporting services to deliver quality healthcare 1 Introduction Welcome to the Quality Assessment and Improvement Workbook. This workbook will
More informationStandard Operating Procedure (SOP) for Reporting Serious Breaches in Clinical Research
Standard Operating Procedure (SOP) for Reporting Serious Breaches in Clinical Research For Completion by SOP Author Reference Number PHT/RDSOP/002 Version V2.0 07 Apr 2016 Document Author(s) Document Reviewer(s)
More informationSTANDARD OPERATING PROCEDURE
STANDARD OPERATING PROCEDURE Title Reference Number Adverse Event Reporting in Clinical Medical Device Trials SOP-RES-033 Version Number 1 Issue Date 08 th Dec 2015 Effective Date 22 nd January 2016 Review
More informationBASINGSTOKE AND NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST
BASINGSTOKE AND NORTH HAMPSHIRE HOSPITALS NHS FOUNDATION TRUST SUMMARY This policy provides guidance for providing safe maintenance procedures for assets and buildings owned by the Trust. 1 BASINGSTOKE
More informationJOB DESCRIPTION. 1 year fixed term. Division A Pharmacy. University Hospitals Birmingham. Advanced Clinical Pharmacist Trials.
JOB DESCRIPTION JOB TITLE: Pharmacy Technician Haematology Clinical Trials PAY BAND: Agenda for change - Band 5 TERMS AND CONDITIONS DEPARTMENT/DIVISION: BASED AT: REPORTS TO: PROFESSIONALLY RESPONSIBLE
More informationSOUTH STAFFORDSHIRE AND SHROPSHIRE HEALTHCARE NHS FOUNDATION TRUST
SOUTH STAFFORDSHIRE AND SHROPSHIRE HEALTHCARE NHS FOUNDATION TRUST Document Version Control Document Type and Title: Authorised Document Folder: New or Replacing: Document Reference: Version No. v4.0 Medical
More informationProvision of Wigs Policy
Post holder responsible for Procedural Document Author and post holder of Policy Division/Department responsible for Procedural Document Contact details Lead Cancer Nurse Tina Grose, Lead Cancer Nurse
More informationNon Medical Prescribing Policy
Non Medical Prescribing Policy Author: Sponsor/Executive: Responsible committee: Ratified by: Consultation & Approval: (Committee/Groups which signed off the policy, including date) This document replaces:
More informationDOCUMENT CONTROL Title: Use of Mobile Phones and Tablets (by services users & visitors in clinical areas) Policy. Version: Reference Number: CL062
DOCUMENT CONTROL Title: Version: Reference Number: Use of Mobile Phones and Tablets (by services users & visitors in clinical areas) Policy 5 CL062 Scope: This Policy applies all employees of the Trust,
More informationClinical Coding Policy
Clinical Coding Policy Document Summary This policy document sets out the Trust s expectations on the management of clinical coding DOCUMENT NUMBER POL/002/093 DATE RATIFIED 9 December 2013 DATE IMPLEMENTED
More informationHEALTH AND SAFETY MANAGEMENT AT UWE
HEALTH AND SAFETY MANAGEMENT AT UWE Introduction This document sets out the University s strategic approach to health and safety management. It contains the Statement of Intent that outlines the University
More informationNURSE-LED DISCHARGE POLICY
THE NORTH WEST LONDON HOSPITALS TRUST Name: NURSE-LED DISCHARGE POLICY Communication 1. All staff must be aware of this policy. 2. All first line managers must have read and have a working knowledge of
More informationNational Radiation Safety Committee, HSE
TO: FROM: Holders of Medical Ionising Radiation Equipment National Radiation Safety Committee, HSE DATE: 04 March 2010. RE: Guidance on Responsibilities in European Communities (Medical Ionising Radiation
More informationUCL MAJOR INCIDENT TEAM MAJOR INCIDENT PLAN. Managing and Recovering from Major Incidents
UCL MAJOR INCIDENT TEAM MAJOR INCIDENT PLAN Managing and Recovering from Major Incidents June 2017 MAJOR INCIDENT PLAN - June 2017 Title Primary author (name and title) UCL Major Incident Plan (public
More informationAdministration of Intrathecal Cytotoxic Chemotherapy in NHS Grampian
Administration of Intrathecal Cytotoxic Chemotherapy in NHS Grampian Lead Author/Coordinator: Jeff Horn / Sarah Howlett Macmillan Haematology CNS/ Pharmacist Reviewer: Gavin Preston Consultant Haematologist
More informationRG 103 Accreditation for the Inspection of Electrical Equipment in Quarries
This publication contains policy, recommendations and guidance applicable to UKAS accredited inspection bodies RG 103 Accreditation for the Inspection of Electrical Equipment in Quarries Contents Section
More informationCLINICAL AND CARE GOVERNANCE STRATEGY
CLINICAL AND CARE GOVERNANCE STRATEGY Clinical and Care Governance is the corporate responsibility for the quality of care Date: April 2016 2020 Next Formal Review: April 2020 Draft version: April 2016
More informationTelemedicine Legal. Telemedicina e e-saúde 2011/12 Pedro Brandão
Telemedicine Legal Telemedicina e e-saúde 2011/12 Pedro Brandão References Sources are indicated by [RefSource] where the complete citation will be at the end Inside citations will be From: CitationSource
More informationSafeguarding Annual Assurance Self-assessment Tool. Sheffield Health and Social Care NHS Foundation Trust
Safeguarding Annual Assurance Self-assessment Tool Sheffield Health and Social Care Foundation Trust Introduction - About this Self-assessment This self-assessment is an assessment of your own internal
More informationStandard Operating Procedure (SOP) for Reporting Urgent Safety Measures in Clinical Research
Standard Operating Procedure (SOP) for Reporting Urgent Safety Measures in Clinical Research For Completion by SOP Author Reference Number PHT/RDSOP/006 Version V1.1 07 Apr 2016 Document Author(s) Document
More informationReplacement Of Balloon Retained Gastrostomy (BRG) Procedure Introduction and Aim
Reference Number: UHB 189 Version Number: 2 Date of Next Review: 10 th Dec 2018 Previous Trust/LHB Reference Number: Replacement Of Balloon Retained Gastrostomy (BRG) Procedure Introduction and Aim The
More informationCONTROLLED DOCUMENT. All Managers. All Employees. Page 1 of 30. Health and Safety Policy Issued: 26/01/2017
CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Health and Safety Policy Policy Health and Safety Policy covering scope and responsibilities for health and safety in UHB
More informationPolicies, Procedures, Guidelines and Protocols
Policies, Procedures, Guidelines and Protocols Document Details Title Trust Ref No 1535-27280 Local Ref (optional) NA Main points the document This policy sets out the arrangements for the management of
More informationRecommendations on outsourcing to cloud service providers (EBA/REC/2017/03)
Recommendations on outsourcing to cloud service providers (EBA/REC/2017/03) These Recommendations of the European Banking Authority (EBA) are addressed to competent authorities as defined in point (i)
More informationLEARNING FROM DEATHS POLICY
Issue number: 1st Edition LEARNING FROM DEATHS POLICY Author with contact details Dr Neil Mercer, Associate Medical Director for Clinical Governance Neil.mercer@aintree.nhs.uk tel. 529-5152 Original Issue
More informationSOUTH EASTERN TRUST. Point of Care Testing (POCT) Policy Ellie Duly, Chair POCT Committee. Approval date: Operational Date: November 2014
Policy Code: SET/PtCtCare (186) 2014 SOUTH EASTERN TRUST Title: Author(s) Point of Care Testing (POCT) Policy Ellie Duly, Chair POCT Committee Ownership: Approval by: South Eastern Trust Ratified Directors
More informationNumber: Version Number: 4. On: February 2015 Review Date: February 2018 Distribution: Essential Reading for:
Policy for the Handling of Patient s Cash, Valuables and Property CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: PURPOSE Controlled Number: Document Version Number: 4 Controlled Sponsor: Controlled Lead:
More informationCourse of Study for the Certification of Competence in Administering Intravenous Injections
R A D I O G R A P H Y Course of Study for the Certification of Competence in Administering Intravenous Injections 1 2 Course of Study for the Certification of Competence in Administering Intravenous Injections
More informationConsulted With Individual/Body Date. Last reviewed Mags Shaughnessy Director of Operations 16 August Operations
Root Cause Analysis for Cancer Patients exceeding National Performance Standards Policy Register No: 17005 Status: Public Developed in response to: CWT Version 9 Going Further on Cancer Waits Achieving
More informationPatient Group Direction For The Administration Of Sodium Chloride (0.9%) Via Nebulisation By Physiotherapists Working Within NHS Grampian
NHS Grampian Patient Group Direction For The Administration Of Sodium Chloride (0.9%) Via Nebulisation By Physiotherapists Working Within NHS Grampian Lead Author: Consultation Group: Approver: Highly
More informationHealth & Safety Policy
Health & Safety Policy Reviewed by SLT 31/7/17 Ratified by Governors 30 September 2015 Effective from 1 October 2015 Review scheduled for Autumn 2019 Responsible person Responsible Governor Committee Business
More informationChanges in the Medical Device Legislation; the day after. Jan Bart Hak 1
PPN Najaarsbijeenkomst 21 November 2017 Changes in the Medical Device Legislation; the day after. How much time do we have left? Jan Bart Hak Jan Bart Hak 1 Company Leading consultancy and project management
More informationDocument Number: 006. Version: 1. Date ratified: Name of originator/author: Heidi Saunders, Senior Portfolio Coordinator
including Roles and Responsibilities for the Conduct of Research Studies and Clinical Trials including CTIMPs (Clinical Trials of Investigational Medicinal Products) Document Number: 006 Version: 1 Ratified
More informationLevel 3 NVQ Diploma in Custodial Care ( )
Level 3 NVQ Diploma in Custodial Care (8434-03) Qualification handbook for centres 600/075319 www.cityandguilds.com March 2011 Version 1.1 (Aug 2011) About City & Guilds City & Guilds is the UK s leading
More informationPolicies, Procedures, Guidelines and Protocols
Policies, Procedures, Guidelines and Protocols Document Details Title Complaints and Compliments Policy Trust Ref No 1353-29025 Local Ref (optional) N/A Main points the document This policy and procedure
More informationDelegation to Band 3 and 4 Nursing Unregistered Support Workers Guidance for Staff and Managers. Version No.1 Review: November 2019
Livewell Southwest Delegation to Band 3 and 4 Nursing Unregistered Support Workers Guidance for Staff and Managers Version No.1 Review: November 2019 Notice to staff using a paper copy of this guidance
More informationHealth and Safety Policy
Document reference: 210A2015 Date: March 2015 Health and Safety Policy Index 1.0 Introduction 2 2.0 Health and safety policy statement 2 3.0 Health and safety responsibilities 3 4.0 Health and safety risks
More informationDELEGATION OF DUTY POLICY
DELEGATION OF DUTY POLICY The OHC&AT Board of Directors has agreed this Policy and as such, it applies across the organisation 29 th June 2018. Jay Mercer Darren Coghlan Chair of OHCAT Board Chair of OHC
More informationThe Prevention and Control of Violence & Aggression Policy CONTROLLED DOCUMENT
CONTROLLED DOCUMENT The Prevention and Control of Violence & Aggression Policy CATEGORY: CLASSIFICATION: PURPOSE Controlled Document Number: Version Number: 3 Controlled Document Sponsor: Controlled Document
More information