Quality and Patient Safety Expectations

Patient safety lies at the heart of excellence in healthcare provision, and Northern Devon Healthcare Trust’s aim is to have no avoidable patient deaths and no avoidable harm to patients.  Patient safety is inherent in every aspect of the care we deliver to our patients, and is seen as everyone’s responsibility, from corporate to individual.

VTE Risk Assessment

  • We expect every patient, on admission, to be assessed for their risk of developing venous thromboembolism whilst they are in our care.
  • We expect that any patients who are identified as at ‘at risk’ be prescribed the appropriate chemical and mechanical prophylaxis (dependant on any identified contraindications).
  • We expect our patients’ risk to be reassessed 24 hours after admission or on the first postoperative day.

More information

Venous Thromboembolism (VTE) Policy

Record Keeping

  • We expect all staff, regardless of their role, to comply with the legal requirements and professional standards of record keeping.
  • Documentation should be legible, relevant and should be a clear indication of the clinical status of, and ongoing plan of care for, the patient.
  • Each entry in the healthcare record should be dated (DD/MM/YY) and timed (using the 24 hour clock), and signed.  The documenter’s name should also be printed and their designation documented.

More information

Clinical Record Keeping Policy


  • We expect all staff to follow the Medicines Policy when prescribing medication for patients.
  • We expect prescribers to write legibly, indicate the route of administration, dose, and duration (where appropriate).
  • We expect prescribers to print their name, and to document their GMC number.
  • If a medication is changed, stopped or needs to be omitted, it is expected that this is documented in the healthcare record

More information

Medicines Policy

Medicines Reconciliation

  • We expect our patients to continue, where appropriate, on the same medications that they were taking prior to admission.
  • We expect a medicines reconciliation form to be completed on admission and for the source of the information (e.g. patient, carer, patient’s GP) to be indicated.

More information

Contact Ward Pharmacist / Pharmacy Team

WHO Surgical Safety Checklist

  • We expect all members of the theatre team, including the anaesthetist and surgeon, to participate in the completion of the WHO Surgical Safety Checklist.
  • We want all members of the team to feel that they are able to raise any safety issues before, during, and after surgery.

More information

NPSA Website

Hand Hygiene

  • We expect every member of staff, regardless of their role, to comply with hand hygiene requirements, and we will challenge any aspects of poor practice with the individual.

More information

Standard Infection Control Precautions Policy

Peripheral Vascular Catheter / Central Line Insertion

  • Whenever a peripheral vascular catheter or central line is inserted, we expect the appropriate high impact intervention care bundle to be used.
  • We expect compliance with the intervention to be documented in the appropriate part of the healthcare record.

More information

High Impact Interventions

Urinary Catheters

  • We expect that urinary catheters will only be used for patients following the careful consideration of alternative methods of management
  • Following insertion, we expect the need for a patient to have a urinary catheter to be reviewed on a regular basis, and expect that the urinary catheter will be removed as soon as it is practicable to do so.

More information

Urinary Catheter in Adults policy

Last updated: October 3, 2017