Patient Safety and Quality Policies

2015 KW EQIA receipt of applications for detention Administration of Subcutaneous Chemotherapy in the Community Guideline Adult Intraosseous Cannulation using the EZ-IO Device for Emergency Intravascular Access Protocol Advance & Emergency Care Pathway (AECP) For Children With Life Threatening or Life Limiting Illness and EQIA Alcohol and Substance Misuse Procedure Alcohol Detoxification in UHW and UHL (Symptom Triggered) All Wales Paediatric Advance Care Plan All Wales Paediatric Advance Care Plan Policy for Patients under 18 with Life Threatening Illness EQIA All Wales POCT Governance Policy All Wales Policy for Medicines Adminstration, Recording,Review,Storage and Disposal All Wales Safeguarding Adults Policy and Procedures Allocation of RC and Nominated Deputy Procedure Antimicrobial Agents Policy Apomorphine Administering Procedure Via Sub-Cutaneous Infusion Device to In-Patients with Parkinson’s Disease Application for admission to hospital under Part II of the MHA Policy and Procedure Approval of Gene Therapy Medicinal Products and Gene Therapy Investigational Medicinal Products Procedure & EHIA	M Management of Performance Concerns Framework Management of Ovarian Cysts and Other Adnexal type Cyst Imaged on Ultrasound Management of Parenteral Cytotoxic Chemotherapy Policy and EQIA Management of Parenteral Cytotoxic Chemotherapy Procedure Management of patients/visitors in possession of alcohol or unprescribed/ illegal substances policy & procedure and EQIA Management of Throat Pack Policy and Procedure and EQIA Managing Breaches of Good Clinical Practice or the Study Protocol Medical Equipment Management Policy Medical Equipment Management Procedure Mycobacterium Tuberculosis and EQIA
B Bedrails Procedure Blood Component Transfusion Policy and EHIA Blood Component Transfusion Procedure	N Non Medical Prescribing Governance Framework Nutrition and Catering Policy/EHIA for Inpatients Nutrition and Catering Procedure for Inpatients
C Chaperone Policy and EQIA Choice Protocol Community Treatment Order Policy & EHIA Community Treatment Order Procedure Conduct of Hospital Managers Power of Discharge Protocol Confirmation of an Expected Death Policy Conscious Sedation in Adults Procedure Consent to Examination or Treatment under the MHA 1983 Procedure Consent to Imaging Examination and Treatment Policy and EQIA Covert Medication Administration Covert Medication Flowchart Creutzfeldt Jakob-Disease (CJD) Procedure and EHIA Crisis Resolution and Home Treatment	O Obtaining Capacity and Capability Confirmation for Research to Start Operational Policy for Integrated Community Mental Health Teams and EQIA Operational Procedure for Rapid Access Chest Pain Clinic
D Data Protection Guidance For Researchers and EQIA Defibrillation Guidelines Diagnosis and Management of Vitamin D Deficiency in Children and Adults Guidelines Discharge Against Clinical Advice Drug Testing in Adult Mental Health Settings Operating Procedure	P / Q Paediatric Advance Care Plan Parenteral Infusion Pumps Policy and EQIA Parenteral Infusion Pump Procedure Parenteral Nutrition Procedures for Adult Patients Patient Access Policy and EQIA Patient Identification Policy and EQIA Patient Rights Information to Detained Community Patients Policy and Procedure Interim Clinical Commissioning Urgent Policy Statement Perinatal Post-Mortem: Perinatal Post-Mortem Investigation of Fetal and Neonatal Deaths (England, Scotland and Wales) Peri-Operative Pain Management Guidelines in Children Pharmacy Investigational Medicinal Product Management within C&V UHB SOP and EQIA Polisi Cymru Gyfan Penderfynu Ynghylch Ceisiadau Ariannu Cleifion Unigol (IPFR) (Cymraeg) Point of Care Testing (POCT) Policy and EQIA Point of Care Testing (POCT) Procedure Pressure Ulcer Risk Assessment, Prevention and Treatment Policy & EHIA and Pressure Ulcer Procedure Policy and Procedure for the prevention and Management of Adult In-patient Falls and EQIA Appendices Prevention and Management of Violent and Aggressive Situations and Psychiatric Emergencies Procedure Procedure for the Prevention, Control and Management of Multidrug Resistant Organisms(MDRO) EQIA Producing Written Information for Patients (Guidance)
E Ectoparasitic Procedure and EQIA Equality Diversity and Human Rights Policy and EQIA Exposure of Patients to Ionising Radiation Procedure Exposure of Staff and Public members to Ionising Radiation Procedure Extravasation Procedure and EQIA	R Radioactive Substances Risk Management Policy Radioactive Substances Risk Management Procedure Rapid Tranquilisation Guideline Referrals By Non-Medical Practitioners For Diagnostic Imaging Investigations (Excluding Clinical Trials And Research) Policy and EqIA Referrals By Non-Medical Practitioners For Diagnostic Imaging Investigations (Excluding Clinical Trials And Research) Procedure Referral of Patients Presenting at Community for Emergency Contraception Protocol and EQIA POEC Replacement of Balloon Retained Gastrostomy Procedure and EQIA Research Audit Standard Operating Procedure Research and Development Strategy 2020-2023 Research Governance Procedure Restraint in The Care Management of Patients Aged 16 Years and Over with Impaired Mental Capacity- Policy and Procedure & EHIA Appendix 1 Care plan Appendix 2 Flow Chart Appendix 3 Policy Hand Mitts Resuscitation Procedure Family Witnessed Resuscitation Resuscitation Training Guidelines and EQIA Review of Detention & CTO MHA 1983 Policy and Procedure
F Fetal Remains, Stillbirth and Neonatal Death Procedure	S Search of Patients Persons and Belongings Policy & Procedure and EQIA Section 136 Mental Health Act 1983: Mentally Disordered Persons Found in Public Places and EQIA Section 5(2) Doctor's Holding Power Policy & EHIA Section 5(2) Doctor's Holding Power Procedure Section 5(4) Nurse's Holding Power Policy & EHIA Section 5(4) Nurse's Holding Power Procedure Section 17 Leave of Absence Guideline Sepsis Pathway Protocol Staff Accessing a Mental Health Assessment Protocol Standard Operational Procedure Research requirements including Good Clinical Practice
G Guide for Power PICC (Peripherally Inserted Central Catheters) solo using Ultrasound and Sherlock using 3CG Guidance Guidelines on Management of Opioid Dependant Individuals Admitted to a UHB Hospital Guidance for Producing Written Information for Patients	T Template Letters for use with the Choice Protocol The Conduct of Power of Discharge Hospital Managers’ Hearings - Protocol The Management of Oral AntiCancer Therapy and EQIA Thromboprophylaxis Policy for Adult Inpatients and EQIA Tracheostomy Guidelines for Acute Adult Inpatients
H Handling Spilled Cytotoxic Drugs Procedure Healthcare Professionals Overseeing Patient INR Self-Testing Services Practice Guidelines and EQIA Hospital Managers Power of Discharge Handbook Hospital Managers Scheme of Delegation Policy & EHIA Hospital Managers Scheme of Delegation Procedure Human Tissue in Clinical Research Management Procedure	U Ultrasound in the Diagnosis of Developmental Hip Dysplasia and Dislocation – A Protocol and EHIA Ultrasound Clinical Governance Policy Ultrasound Clinical Governance Procedure
I / J Incident, Hazard and Near Miss Reporting Policy and EHIA Incident, Hazard and Near Miss Procedure Independent Mental Capacity Advocacy Procedure Infection Control Procedure for Infectious Incidents and Outbreaks in University Health Board Hospitals and EQIA Infection Control Standard Precautions Procedure for Cardiff and Vale University Health Board Hospitals and EQIA Infection Control Procedure for the Management of Patients known or Suspected to have Clostridium Dificille Infection Infection Control Procedure for Mycobacterium Tuberculosis (TB) and EQIA Insertion, Management and Removal of Nasal Bridle Fixation Devices for Naso-Enteral Tubes in Adults Procedure and EQIA Insertion of a Flocare® Bengmark Naso-Intestinal Tube, Confirmation of correct position and on-going care in adults’ procedure Insertion of a Nasogastric Tube, Confirmation of Correct Position and Ongoing Care in Adults, Children and Infants and Neonates Procedure Ionising Radiation Risk Management Policy and EQIA Joint s117 Aftercare Procedure Joint Policy on Section 117 of the Mental Health Act 1983 Joint Procedure on Section 117 of the Mental Health Act 1983	V / W Working with Volunteers Varicella-zoster (Chickenpox/shingles) Infection Control Procedure and EQIA Viral Gastroenteritis (Norovirus) Infection Control Procedure Viral Hepatitis Procedure and EQIA
K / L Labelling of Specimens Procedure	X/Y/Z