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					Reducing Needless Harm and Death

    Workstream Leads: Hester Wain, Emma Vaux, Alison Huggett
                 Project Manager: Becky De’Ath
One of the most striking cases concerns a patient who
suffered no less than three falls within five days

 “I walked into Ward 10. My mother was lying on grey marley tiled floor,
    lying full stretch out on the grey marley tiled floor. Some effort had
    been made to remove all the blood. It was smeared all over the floor.
    You could not see a hair on her head. It was completely swathed in
    bandages. And there was a lady doctor holding my mother’s head in
    her hands like that, and I said: oh Mum, what have they done to you?
    And I looked at this doctor holding my mother’s head and I said: this
    is my mother. As cold and as calculated as anything, her retort as
    fast as anything was: I have got a mother too. There was no
    compassion in that woman whatsoever.”
Independent Inquiry into care provided by Mid Staffordshire
NHS Foundation Trust January 2005 – March 2009 Volume I
Chaired by Robert Francis QC
 Recommendation 1:
 The Trust must make its visible first priority the delivery of a high-class standard of care to
    all its patients by putting their needs first. It should not provide a service in areas where
    it cannot achieve such a standard.
 Recommendation 5:
 The Board should institute a programme of improving the arrangements for audit in all
    clinical departments and make participation in audit processes in accordance with
    contemporary standards of practice a requirement for all relevant staff. The Board
    should review audit processes and outcomes on a regular basis.
 Recommendation 15:
 In view of the uncertainties surrounding the use of comparative mortality statistics in
    assessing hospital performance and the understanding of the term ‘excess’ deaths, an
    independent working group should be set up by the Department of Health to examine
    and report on the methodologies in use. It should make recommendations as to how
    such mortality statistics should be collected, analysed and published, both to promote
    public confidence and understanding of the process, and to assist hospitals in using
    such statistics as a prompt to examine particular areas of patient care.
How many patients does healthcare harm?
 8.6% and 11.7% of hospital admissions were associated with adverse events
  (Vincent et al 2001, Brennan 1991, Wilson 1995, Bab-Akbari 2007, Sari et al 2007)
 10% of all patients who are admitted to hospital suffer some form of harm (The
  House of Commons Health Committee’s Patient Safety Report June 2009)
 13% of patients had care that was harmful (McGlynn 2003)
 6% of patients died in hospital due to sub-optimal care (Hayward and Hofer 2001)
 11% of deaths in Intensive Care from deficiencies in care (NCEPOD 2005)
 8.5% of patients deaths were contributed to by preventable adverse events
  (Preventable Incidents, Survival and Mortality Study PRISM 2006)
 10% (15/150) patient deaths reviewed were thought to be avoidable (3% 5/150
  probably) (Wain and Vaux 2010)
How does the NHS measure death?

 Hospital Standardised Mortality
  Ratio (HSMR)
 Summary Hospital-level Mortality
  Indicator (SHMI)
 Observed number of deaths
 % Crude mortality (IHI definition)
 Avoidable/Preventable mortality
How can we reduce harm and mortality?

  Work harder           So what should we do?
  Learn more
                          Identify the issues
  Do better
                          Develop the solutions
  Remember everything
                          Try small steps of change (PDSA)
  Forget nothing
                          Measure the success
                          Disseminate the practice

 Does this work?          Monitor sustainability
 Standardised tools for systematic healthcare record reviews to identify
  issues and provide baseline data for adverse event/harm, and
  percentage of avoidable deaths:
    • Use of the Mortality Review Template (MRT) in 8/9 Acute Trusts
    • Use of the Trigger Tool (TT) in 6/9 Acute Trusts
 Funding provided by the workstream to participating Trusts to
  encourage healthcare record reviews
 Baselines for internal improvement monitoring generated by
  participating Trusts
 Themes from MRT and TT reviews shared with all the workstreams
 Improvement projects shared between workstream members
 Patient representation and participation
• Mortality Review Template
• Trigger and Adverse event management flow chart
• Mortality Matrix
• Escalation protocol for deteriorating patient
• Escalation sticker for deteriorating patient
• Learning from serious incidents using SIMMAN
• Nursing Quality Framework
• Staff Nurse development programme
• AKI (acute kidney injury) care bundle
• Hospital associated pneumonia Quality Improvement Project
% Avoidable deaths
= Suboptimal care - different care MIGHT have made a difference (possibly
avoidable death)
+ Suboptimal care WOULD REASONABLY BE EXPECTED to have made a
difference (probably avoidable death)

                   September 2010 February 2011           % reduction
      Trust 1            8.0%                7.0%            12.5%
      Trust 2             0%                 2.5%           increase
      Trust 3            6.3%                4.8%            23.8%
      Trust 4            2.0%                2.0%                 0
      Trust 5            10.0%               4.0%                60%

                Aim: To reduce avoidable deaths by 10% by 2011
             A sub-group of the Patient
            Safety Committee has been
                   set up to review
           documentation standards and
Benefits      the physical state of the
                patient notes. This is
                specifically related to
             the finding in the Mortality
                Review in April 2011.

           From participating in the PSF we have a
               full programme of patient safety
           campaigns across the year which cover
              all elements of patient safety. This
               campaign programme has been
             modified for the forthcoming year to
            include even more with most months
                    now having two themes.
PSF, SHA and
Saving Lives: Reducing Avoidable Deaths in
  Hospital Conference (London May-10)
Preventable Incidents, Survival and Mortality
  Study PRISM Study day (London Sep-10)
Case Note Review: Implementing the Health
  Select Committee Recommendations Meeting
  (London Mar-11)
Reducing and Measuring Avoidable Mortality in
  Hospitals Conference (Manchester Jul-11)
Reducing & Measuring Avoidable Mortality in
  Hospitals Conference (London May-12)
East Sussex Healthcare NHS Trust
Stepping Hill Hospital (Stockport)
Western Sussex Hospitals NHS Trust
Yeovil District Hospital NHS Foundation Trust
Mid Yorkshire Hospitals NHS Trust
Northumbria Healthcare NHS Foundation Trust
Thank you
Patient safety team, Royal Berkshire NHS Foundation Trust
PSF Workstream Leads: Emma Vaux, Alison Huggett

Becky De’Ath (PSF Workstream Project Manager)
Patient Safety Federation participating trusts: Basingstoke and North
Hampshire Foundation Trust, Berkshire East PCT, Berkshire West PCT,
Buckinghamshire Hospitals NHS Trust, Hampshire Community Health Care,
Heatherwood and Wexham Park Hospitals NHS Foundation Trust, Isle of Wight
NHS, Milton Keynes Hospital NHS Foundation Trust, Nuffield Orthopaedic
Centre NHS trust, Oxford Radcliffe Hospitals NHS Trust, Oxfordshire PCT,
Portsmouth Hospitals NHS Trust, Royal Berkshire NHS Foundation Trust, South
Central Ambulance Trust, Southampton University Hospitals NHS Trust,
Winchester and Eastleigh Healthcare NHS Trust, Solent Healthcare,
Buckinghamshire PCT.

Contact email:
   Avoidable death definition
 CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy)

    Grade 0 No Suboptimal care
    Grade 1 Suboptimal care, but different management would have made
            no difference to the outcome
    Grade 2 Suboptimal care - different care MIGHT have made a
            difference (possibly avoidable death)
    Grade 3 Suboptimal care – different care WOULD REASONABLY BE
                     EXPECTED to have made a difference (probably
                     avoidable death)

Reference: Perinantal Institute Revised Reducing Perinatal Mortality
Confidential Case Review Protocol (2006)

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