The NHS Safety Thermometer 10 Steps to Success Series! Understanding how we measure harm in healthcare

1. The NHS Safety Thermometer10 Steps to Success Series!Understanding how we measure harm in healthcare Step 1

2. ‘It may seem a strange principle to enunciate as the very first requirement in a hospitalthat it should do the sick no harm’ Hospitals are only an intermediate stage of civilisation Florence Nightingale, 1859.

3. Adverse events – what’s the global picture? International rates generally quoted about 10% of hospitalizations • Leape 1991 (USA) 3.8% • Vincent 2001 (UK) 11.7% • Wilson 1995 (Aus) 16.6% • Schioler 2001 (Denmark) 9% Common problems • Medication errors • Infections • Procedure-related Most estimate 30-50% preventable • ”Failure to rescue” • DVT/pulmonary embolism • Pressure (decubitus) ulcers, falls etc Source; Ovretveit 2009

4. In England…….. Patient safety incidents in acute care (NPSA), including 'no harm‘ as a % of total treated each year: 5.7% (824,044) Patients with moderate and severe harm % of total treated: 1.2% (178,762) Patients with moderate, severe or fatal harm, % of total treated: 0.4% (5,011)

5. The NHS is data rich…….

6. Measuring Harm

7. In reality it is probably measured like this based on preference……. Point of care Lab data Trigger tools Case note review Adverse Incident Reports

8. Unpacking sources of data Incident Reporting Administrative Data Incident Reporting Case Note Review Point of Care Surveys

9. Administrative Data Incident Reporting Administrative Data Case Note Review Point of Care Surveys

10. Point of care surveys Incident Reporting Administrative Data Case Note Review Point of Care Surveys

11. Maybe the solution lies with using multiple sources of data for a single issue?

12. Triangulation – pressure ulcer example Your patient safety committee have presented a report on the prevalence of pressure ulcers. The data above have been pulled for you by the assurance team – what will you tell the Board?