Patient Safety and Quality Policies

UHB 003 - Child Abduction Policy - EQIA

UHB 004 - Infection Control Procedure for Meticillin Resistant Staphylococcus Aureus (MRSA) in Acute Hospitals

UHB 006 - Data Protection Guidance for Researchers

UHB 009 - Interventions Not Normally Undertaken Policy

UHB 011 - Acute Pain Management Guidelines (Adult) and EQIA 

UHB 016 - Domestic Abuse Guidelines for The Emergency Unit and EQIA

UHB 017 - Labelling Of Specimens Policy

UHB 018 - Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) Policy

UHB 019 - Infection Control Protocol For Needlesticks and Similar Sharps Injuries and EQIA

UHB 030 - Provision of Intraoperative Cell Salvage Policy - EQIA

UHB 032 - Advanced and Emergency Care Pathway for Children / Young People with Life Threatening / life limiting illness

UHB 033 - Patient Access Policy - EQIA

UHB 040 - Investigational Medicinal Product (IMP) Management Standard Operating Procedure - EQIA

UHB 044 - Restraint in The Care Management of Patients Aged 16 Years and Over with Impaired Mental Capacity - Policy and Procedure (Appendix 1 - Care plan / Appendix 2 - Flow Chart / Appendix 3 - Policy Hand Mitts)

UHB 045 - Policy and Procedure for the Prevention and Management of Adult In-patient Falls - EQIA

UHB 052 - Referral of Patients presenting at Community Pharmacy for Emergency Hormonal Contraception

UHB 055 - Clostridioides difficile Procedure

UHB 062 - Point of Care Testing (POCT) Policy - EQIA 

UHB 065 - Wales Interim Policy & Procedure for the Protection of Vulnerable Adults from Abuse

UHB 066 - Self-Presentation at Adult Mental Health Premises Protocol

UHB 067 - Insertion, Management and Removal of Nasal Bridle Fixation Devices for Naso-Enteral Tubes in Adults Procedure and EQIA

UHB 068 - Blood Component Transfusion Policy

UHB 075 - Viral Gastroenteritis (Norovirus) Procedure

UHB 076 - Varicella Zoster Procedure & EHIA

UHB 081 - Parenteral Infusion Pump Policy & Procedure

UHB 082 - Medical Equipment Policy & Procedure

UHB 083 - Equality, Inclusion and HR Policy & EQIA

UHB 092 - Chaperone Policy

UHB 096 - Diabetic Ketoacidosis Management Guidelines in Adults within the University Hospital of Wales (UHW) and University Hospital of Llandough (UHL)

UHB 100 - Consent to Examination or Treatment Policy

UHB 101 - Patient Identification Procedure & EQIA

UHB 104 - Choice of Accommodation Protocol for Inpatients Requiring Placement in Residential Nursing Homes

UHB 106 - Policy for the Prevention of Venous Thromboembolism (VTE) in Adult and Teenage Patients & EHIA

UHB 113 - Lasting Power of Attorney Procedure

UHB 114 - Nasogastric Tubes (NG Tubes): Procedure for the insertion of nasogastric feeding tube, confirmation of correct position and ongoing care (for adults, children, infants, and neonates)

UHB 119 - Mental Health Clinical Risk and Risk Mitigation Management Policy

UHB 120 - Quality Policy of the Directorate of Laboratory Medicine (CAVUHB)

UHB 122 - Operational Policy for Integrated Community Mental Health Teams

UHB 123 - Renewal of Detention and Consultation with the Second Professional Policy

UHB 124 - Powers of Discharge Hospital Managers Hearings Conduct Protocol

UHB 132 - Volunteer Strategy

UHB 138 - Incident, Hazard and Near Miss Reporting Policy

UHB 140 - Standard Operating Procedure for the Destruction of Controlled Drugs by Authorised Witnesses - Primary Care

UHB 149 - Infection Control Procedure for Infectious Incidents and Outbreaks in University Health Board Hospitals

UHB 153 - Peri-operative Pain Management in Children

UHB 155 - Policy and Procedure for Pressure Ulcer Risk Assessment, Prevention and Treatment Procedure

UHB 158 - Depot Medication Procedure and Protocol for the Administration of Depot Medication in Community Mental Health Teams]

UHB 162 - Administration of Nebulised Ribavirin in Adults (Haematology) Procedure

UHB 171 - Alcohol, Drug & Substance Misuse Policy

UHB 174 - Search of Patients Persons Belongings Policy and Procedure & EQIA

UHB 175 - Management of Patients / Visitors in Possession of Alcohol or Unprescribed / Unlawful Substances Policy and Procedure & EQIA

UHB 177 - Guidelines for the Use of Rapid Tranquilisation in Adult Inpatients (18-65 years)

UHB 178 - Prevention and Management of Violent and Aggressive Situations & Psychiatric Emergencies Procedure

UHB 184 - Apomorphine Administering Procedure via Sub-Cutaneous Infusion Device to inpatients with Parkinsons Disease

UHB 189 - Replacement of Balloon Retained Gastrostomy (BRG) Procedure

UHB 190 - Use of Antimicrobial Agents Policy

UHB 191 - Swab Instrument and Sharps Count - Policy and Procedure - EQIA

UHB 194 - Extravasation Procedure & EQIA

UHB 196 - Conscious Sedation in Adults Procedure

UHB 200 - Hand Hygiene Infection Control Procedure

UHB 201 - Handling Spilled Cytotoxic Drugs Procedure

UHB 202 - Symptom -Triggered Alcohol Detoxification in CAV UHB Hospitals - Guideline

UHB 205 - Guidelines on the Diagnosis and Management of Vitamin D Deficiency in Children and Adults

UHB 209 - Safe Handling and Administration of Intrathecal Chemotherapy Procedure

UHB 210 - Healthcare Professionals Overseeing Patient INR Self-Testing Services Practice Guidelines & EQIA

UHB 221 - Nutrition and Catering Policy for Inpatients

UHB 222 - Adult Intraosseous Cannulation Protocol using the EZ_IO Device for Emergency Intravascular Access

UHB 224 - Optimising Outcomes Policy and EQIA / Optimising Outcomes Policy Supporting Procedure

UHB 227 - Resuscitation Procedure

UHB 228 - Written Information for Patients Guidance

UHB 229 - Breastfeeding Policy

UHB 230 - Resuscitation Training Guidelines

UHB 231 - Defibrillation Guidelines

UHB 232 - Family Witnessed Resuscitation

UHB 235 - Managing Breaches of Good Clinical Practice or the Study Protocol - Standard Operating Procedure

UHB 236 - Research Audit Standard Operating Procedure

UHB 237 - Mycobacterium Tuberculosis (TB) Procedure Infection Prevention and Control Management within CAVUHB Hospitals & EQIA

UHB 239 - Bedrails Procedure

UHB 243 - Discharge Against Clinical Advice (DACA) Procedure

UHB 244 - Sepsis Pathway

UHB 245 - Organ Donation from the Emergency Unit - Standard Operating Procedure

UHB 260 - Insertion of a Flocare Bengmark Naso-Intestinal Tube, Confirmation of Correct Position and Ongoing Care in Adults' Procedure

UHB 265 - Infection Control Procedure for Viral Hepatitis and EQIA

UHB 267 - Transmission Based Precautions Infection Prevention and Control Procedure

UHB 275 - Ectoparasitic Infestations / Infections: Fleas, Lice and Mites (Scabies) Procedure & EQIA

UHB 278 - Management of a Throat Pack - Policy and Procedure & EQIA

UHB 283 - Policy on the Management of Oral Anticancer Therapy

UHB 302 - Managing Amendments for UHB Sponsored Research - Standard Operating Procedure

UHB 304 - Self-Administration of Medication Procedure for Service Users in the Community

UHB 305 - Integrated Care Pathway for Patient Safety Procedure

UHB 306 - Extra Care Area and Low Stimulus Room Procedure for Hafan y Coed

UHB 308 - Vocational Opportunities Project (VOP) Procedure

UHB 309 - Therapeutic Kitchen Procedure

UHB 310 - Visitors at Hafan y Coed Guidance

UHB 311 - Therapies Hub at Hafan y Coed Operational Procedures

UHB 312 - Emergency Response Procedure for Hafan y Coed Adult Mental Health Unit

UHB 313 - Reassurance Observations System Procedure

UHB 314 - Protocol for the Interface between the Medical Emergency Assessment Unit (MEAU) and Hafan y Coed

UHB 316 - Operational Procedure for Rapid Access Chest Pain Clinic

UHB 317 - Training Requirements for Research Staff, including Good Clinical Practice (GCP)

UHB 322 - Ultrasound Clinical Governance Policy & Procedure

UHB 324 - The Laser Risk Management Policy and Procedure - EQIA

UHB 325 - Guidelines for the Administration of Subcutaneous Chemotherapy in the Community

UHB 328 - Guidelines for the Management of Opioid-Dependent Individuals Admitted to UHB Hospitals

UHB 329 - Management of Parenteral Cytotoxic Chemotherapy Procedure

UHB 330 - Referrals by Non-Medical Practitioners for Diagnostic Imaging Investigations (excluding Clinical Trials and Research) Policy

UHB 331 - Referrals by Non-Medical Practitioners for Diagnostic Imaging Investigations (excluding Clinical Trials and Research) Procedure

UHB 333 - NHS Wales Policy for Making Decisions on Individual Patient Funding Requests (IPFR) - EQIA

UHB 334 - All Wales Paediatric Advance Care Plan (PAC-Plan) Policy for Patients Under 18 Years of Age With Life Threatening or Life Limiting Illness - EQIA

UHB 338 - Standard Operating Procedure for Insertion and Management of Power PICC (Peripherally Inserted Central Catheter) Solo using Ultrasound and Sherlock 3CG Guidance

UHB 340 - Receipt of Applications for Detention under the Mental Health Act 1983

UHB 341 - Mental Health Review Tribunal for Wales Guidance

UHB 342 - Section 136 Mental Health Act 136: Mentally Disordered Persons found in Public Places & EQIA

UHB 343 - Section 117 Joint Mental Health Act Policy

UHB 344 - Ionising Radiation Risk Management Policy

UHB 345 - Exposure of Patients to Ionising Radiation Procedure

UHB 347 - Procedure for the Prevention, Control & Management of Multi Drug Resistant Organisms (MDRO) including Carbapenemase Resistant Organisms (CRO), Meticillin Resistant Staphylococcus Aureus (MRSA) and Glycopeptide Resistant Enteroccoci (GRE)

UHB 348 - Blood Component Transfusion Procedure

UHB 349 - Creutzfeldt-Jakob Disease (CJD) and Variant CJD (vCJD) Minimising the Risk of Transmission Infection Prevention & Control Procedure

UHB 353 - Ultrasound in the Diagnosis of Developmental Hip Dysplasia and Dislocation (Protocol) & EHIA

UHB 364 - Venepuncture for Non-NMC Registered Research Staff Policy

UHB 365 - Procedure for Non-NMC Registered Research Delivery Staff to Perform Venepuncture

UHB 366 - Point of Care Testing (POCT) Procedure

UHB 367 - Nutrition and Catering Procedure for Inpatients

UHB 368 - Management of Simple Ovarian and other Adnexal Cysts Imaged on Ultrasound

UHB 370 - Fetal Remains, Stillbirth and Neonatal Death Procedure

UHB 379 - All Wales Policy for Medicines Administration, Recording, Review, Storage and Disposal

UHB 381 - Drug Testing in Adult Mental Health Settings Operating Procedure

UHB 382 - Staff Accessing a Mental Health Assessment Protocol

UHB 387 - Protocol for Crisis Resolution & Home Treatment Teams (CRHTT) Interface with Welsh Ambulance Service Trust (WAST)

UHB 390 - Guidelines for the Management of Acute Inpatient Adult Patients with a Tracheostomy

UHB 402 - Covert Medical Administration & Covert Medical Flowchart

UHB 403 - Intraoperative Cell Salvage Procedure - EHIA

UHB 405 - All Wales POCT Governance Policy

UHB 407 - Community Treatment Order Policy (Mental Health Act, 1983)

UHB 408 - Community Treatment Order Procedure (Mental Health Act, 1983)

UHB 409 - Hospital Managers' Scheme of Delegation Policy (Mental Health Act, 1983)

UHB 410 - Hospital Managers' Scheme of Delegation Procedure (Mental Health Act, 1983)

UHB 411 - Section 5(2) Doctors' Holding Power Policy (Mental Health Act, 1983)

UHB 412 - Section 5(2) Doctors' Holding Power Procedure (Mental Health Act, 1983)

UHB 413 - Section 5(4) Nurses' Holding Power Policy (Mental Health Act, 1983)

UHB 414 - Section 5(4) Nurses' Holding Power Procedure (Mental Health Act, 1983)

UHB 417 - Guideline on the Management of Post Sexual Exposure to HIV and Other Bloodborne Viruses

UHB 419 - Associate Hospital Managers' Power of Discharge Handbook

UHB 433 - Incident, Hazard and Near Miss Reporting Procedure

UHB 438 - Guideline for Section 17 Leave of Absence (Mental Health Act, 1983)

UHB 439 - Patient Rights to Information to Detained/Community Patients under the Mental Health Act 1983 Policy

UHB 440 - Patient Rights to Information to Detained/Community Patients under the Mental Health Act 1983 Procedure

UHB 441 - Application for Admission to Hospital under Part II of the Mental Health Act 1983 Policy

UHB 442 - Application for Admission to Hospital under Part II of the Mental Health Act 1983 Procedure

UHB 443 - Review of Detention and Community Treatment Order (Mental Health Act, 1983) Policy

UHB 444 - Review of Detention and Community Treatment Order (Mental Health Act, 1983) Procedure

UHB 447 - Carers Procedure

UHB 448 - Obtaining Capacity and Capability Confirmation for Research to Start

UHB 450 - Parenteral Nutrition Procedures for Adult Patients

UHB 451 - Confirmation of an Expected / Unexpected Death Policy

UHB 452 - Labelling of Specimens Submitted to Medical Laboratories Procedure

UHB 461 - Human Tissue in Clinical Research Management Procedure

UHB 463 - Radioactive Substances Risk Management Policy

UHB 464 - Radioactive Substances Risk Management Procedure

UHB 465 - Exposure of Staff and Members of the Public to Ionising Radiation Procedure

UHB 468 - Framework for the Management of Performance Concerns in General Medical Practitioners (GP's) on the Medical Performers List Wales

UHB 475 - Research and Development Strategy 2020 - 2023

UHB 478 - Allocation of Responsible Clinicians and Nominated Deputy (Mental Health Act, 1983) Procedure

UHB 479 - Joint Procedure on Section 117 - Mental Health Act, 1983

UHB 483 - Activation of Emergency Unit Massive Haemorrhage Protocol (Paediatric)

UHB 484 - Non-Medical and Dental Prescribing Governance Framework

UHB 491 - Consent to Examination or Treatment Under the Mental Health Act 1983 Policy and Procedure

UHB 492 - Approval of Gene Therapy Medicinal Products (GTMP) and Gene Therapy Investigational Medicinal Products (GTIMP) Procedure & EHIA

UHB 500 - Interim Clinical Commissioning Urgent Policy - Perinatal Post-Mortem Investigation of Fetal and Neonatal Deaths

UHB 502 - Deteriorating Patient Policy

UHB 505 - Observation & Enhanced Engagement Procedure

UHB 507 - Electro-Convulsive Therapy (ECT) Procedural Guidance

UHB 509 - Clinical Audit Policy

UHB 510 - Procedure for Review and Implementation of NICE, Health Technology Wales Guidance and All Wales Medicine Strategy Group

UHB 513 - Welsh Language Inpatient Policy (Cymraeg)

UHB 518 - Paediatric Major Haemorrhage Protocol