127 Enhancing patient safety: a comprehensive approach to the national patient safety alert – NatPSA/2023/010/MHRA in palliative and end of life care

<h3>Introduction</h3> In response to the Medicines and Healthcare products Regulatory Agency (MHRA) alert August 2023 regarding the safe use of medical beds, bed rails, bed levers, and lateral turning devices, a multidisciplinary team (MDT) programme was designed by the lead Occupational Therapist. This programme was implemented across the hospice continuum. MHRA reports 18 deaths, and 54 serious injuries linked to these devices over five years, with over 60% of incidents occurring in community settings and 33% involving patients aged 65 and older. <h3>Method</h3> To locate legacy devices, all 527 patients under hospice care were contacted. The risk factors identified by the MHRA informed the development of a risk matrix, categorising patients as high or low risk. High-risk patients were triaged by an Occupational Therapist (OT), who assigned them to the appropriate clinical team. Low-risk patients received information leaflets with self-referral indicators. The OT conducted training sessions for clinical staff. An electronic risk assessment template was created with a clinical data analyst, and e-training reflecting the updated guidelines was made mandatory. Data coding was added to highlight patients needing assessments and document completion. Daily fluctuations in patient numbers required bi-weekly reviews to ensure accuracy. <h3>Results</h3> Of the 527 patients, 397 (75%) were contacted. 67 (17%) had devices needing assessment: 33 (49%) were high risk, and 27 (40%) were low risk. 100% of high-risk patients received a face-to-face risk assessment. 6% had the device removed. The remaining patients were referred to the clinical audit team for the next review, ensuring a proportionate response by March 2024. <h3>Conclusion</h3> This programme substantially improved patient safety and ensured compliance with the MHRA alert, yielding significant advancements in risk assessment protocols and increasing awareness among healthcare professionals, carers, and patients. The processes are now fully integrated across the organisation, fostering collaboration and more proactive management of patient care.