Workstream Leads: Hester Wain, Emma Vaux, Alison Huggett Project Manager: Becky De’Ath

1. Workstream Leads: Hester Wain, Emma Vaux, Alison Huggett Project Manager: Becky De’Ath Reducing Needless Harm and Death

2. 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.”

3. 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.

5. How many patients does healthcare harm? 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) DEATH • 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)

6. Hospital Standardised Mortality Ratio (HSMR) Summary Hospital-level Mortality Indicator (SHMI) Observed number of deaths % Crude mortality (IHI definition) Avoidable/Preventable mortality How does the NHS measure death?

7. How can we reduce harm and mortality? So what should we do? • Work harder • Learn more • Do better • Remember everything • Forget nothing • Identify the issues • Develop the solutions • Try small steps of change (PDSA) • Measure the success • Disseminate the practice • Monitor sustainability Does this work?

8. Achievements • 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

9. Toolkit • 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

10. % 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) Aim: To reduce avoidable deaths by 10% by 2011

11. A sub-group of the Patient Safety Committee has been set up to review documentation standards and the physical state of the patient notes. This is specifically related to the finding in the Mortality Review in April 2011. Benefits 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. 

12. Dissemination: 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

13. 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: hester.wain@royalberkshire.nhs.uk 

15. Avoidable death definition CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) Grade 0 No Suboptimal careGrade 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)