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The NHS Safety Thermometer10 Steps to Success Series!
Understanding how we measure harm in healthcare
Step 1
‘It may seem a strange principle to enunciate as the very first requirement in a hospital
that it should do the sick no harm’
Florence Nightingale, 1859.
Hospitals are only an intermediate stage of civilisation
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
Source; Ovretveit 2009
Adverse events – what’s the global picture?
• ”Failure to rescue”• DVT/pulmonary embolism • Pressure (decubitus) ulcers, falls etc
Most estimate 30-50% preventable
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)
In reality it is probably measured like this based on preference…….
Adverse Incident Reports
Case note review
Point of care
Lab dataTrigger tools
Unpacking sources of dataIncident Reporting
Incident Reportin
g Administrative Data
Point of Care Survey
s
Case Note
Review
Point of care surveys
Incident Reportin
g
Administrative Data
Point of Care Survey
s
Case Note
Review
Triangulation – pressure ulcer exampleResearch Admin
DataAdverse Event Safety
ThermometerAudit
Pressure Ulcers 7%
prevalence(category II-IV)
0.3% prevalence(all categories)
383
Reports each year
8.2% prevalence(category II-IV)
Included in GTT as harm as a count (no prevalence data available)
Your patient safety committee have presented a report on the prevalence of pressure ulcers.
The data above have been pulled for you by the assuranceteam – what will you tell the Board?