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SPSPP Undetected Harm Workshop 2 (23 rd March)

SPSPP Undetected Harm Workshop 2 (23 rd March) . Agenda. Welcome, introductions & apologies Summary of Workshop 1 – 9 th Feb 2012 NHS board feedback on using the Undetected Harm Index Reporting Progress & Data Next steps. Introduction.

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SPSPP Undetected Harm Workshop 2 (23 rd March)

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  1. SPSPP Undetected Harm Workshop 2 (23rd March)

  2. Agenda • Welcome, introductions & apologies • Summary of Workshop 1 – 9th Feb 2012 • NHS board feedback on using the Undetected Harm Index • Reporting Progress & Data • Next steps

  3. Introduction Use the marker at the top of the WebEx window to indicate which Board you are from

  4. Summary of Workshop 1 – 9th Feb 2012 • Review progress using NHS Institute’s Paediatric Trigger Tool • Positive Feedback: • multi-disciplinary collaboration; • case note review process – helpful; • highlights areas for improvement. • Negative Feedback: • Triggers don’t relate to care delivered; • lack of detection of harm - impact on staff engagement; • many issues already addressed by SPSPP; • randomisation challenges.

  5. SPSPP Paediatric Trigger Tool Data (Jan 2012)

  6. Output of Workshop 1 – 9th Feb 2012 • Structured case note review • Aim of review – identify undetected harm. • What causes harm in our hospitals - identified other areas to be incorporated: • child protection; • failure to escalate / escalation failure; • lab results (not all applicable – is the follow-up better question?). • Structure of review – follow admission

  7. SPSPP Undetected Harm

  8. Aim of SPSPP Undetected Harm Review

  9. Next Steps • Test: • methodology – random / selected case notes; • process – do the questions lead to identification of undetected harm? • measurement – how do we know we’re making an improvement?

  10. Linking Activities – Delivering the Safe Ambition SPSPP Aims Undetected Harm Reviews Avoidable Harm in Paediatric Wards Serious Harm Index

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