1. Patient Safety

2. Learning Objectives By the end of this session you should be able to; Give examples of areas of concern for patient safety and the situation in Wales Discuss and outline the work of 1000 Lives Improvement Service and the links to patient safety Emma.thomas13@wales.nhs.uk

3. How many of you think you are likely to harm your patients? Emma.thomas13@wales.nhs.uk

4. Betsan’s Story 1000livessec@wales.nhs.uk

5. Patient Stories How did Betsan’s story make you feel??? Patient stories can: Evoke strong feelings in everyone Show a different side to the story Should not lay blame 1000livessec@wales.nhs.uk

6. Theme Park Safety Odds of sustaining an injury at theme park is one in nine million. More likely than injury due to a shark attack The International Association of Amusement Parks (IAAPA)

7. 1000 Lives Plus

8. Healthcare Mortality In 2013, 893 people were recorded as dying from complications of medical and surgical care in England and Wales More than one in ten people admitted to hospital are harmed unintentionally by its care. There is a one in 300 chance of accidental death through errors in care. ONS Mortality Statistics for England and Wales 2013

9. Prudent Healthcare? 11% of hospital deaths analysed resulted from unrecognized or untreated deterioration in their condition. 21% of ICU admissions were avoidable. Potential prevention of 1600 ICU admissions in Wales costing £12 million. Emma.thomas13@wales.nhs.uk

10. Patient Safety These statistics are the same as; 3,283 patients dead through preventable error, another 7,000 suffer severe harm Equivalent to 9 medium size aircraft (Boeing 737/Airbus A320) being written off with total loss of life every year………..in the UK!

11. Source: Don Berwick, IHI (Boston) The First Law of Healthcare Improvement “ Every system is perfectly designed to achieve exactly the results it gets.” We all work within systems that make it impossible NOT to harm and kill our patients

12. Aim of 1000 Lives Improvement 1000 Lives Improvement is the national quality improvement service for NHS Wales. It supports organisations and individuals, to deliver the highest quality and safest healthcare for the people of Wales. 1000livessec@wales.nhs.uk

13. What does 1000 Lives do? Improvement Programmes Ensuring Patient and Person Driven Care 1000 Lives Improvement Associates 1000 Lives Improvement Student and Educator Community Improvement Methodology Publications and Resources 1000livessec@wales.nhs.uk

14. Improvement Programmes 1000 Lives Improvement runs a series of improvement programmes which include: improving stroke services, transforming maternity services, reducing falls in the community, rapid response to acute illness, reducing infection, enhanced recovery after surgery better treatment for those suffering from mental health disorders 1000livessec@wales.nhs.uk

15. Patient Safety Campaigns 1000livessec@wales.nhs.uk

16. 1000 Lives Approach 1.Concentrate on the points where averse events occur 2.Create bundles of evidence based interventions 3.Measure compliance/reliability with these bundles 4.Decide what outcome will be affected by reliable implementation of these bundles and measure it Emma.thomas13@wales.nhs.uk

17. Where do Adverse Events/ Omissions Occur? Transfer of information Handovers Hand offs Admissions Discharge Patient information ‘Lack of communication is killing our patients’ – Pronovost 2002

18. Improving Quality Together

19. Learning Objectives You should be able to; Give examples of areas of concern for patient safety and the situation in Wales Discuss and outline the work of 1000 Lives Improvement Service and the links to patient safety Emma.thomas13@wales.nhs.uk

20. Emma Thomas Improving Quality Together Lead for Higher Education http://www.iqt.wales.nhs.uk/home http://www.1000livesplus.wales.nhs.uk/student-educator- community (E) emma.thomas13@wales.nhs.ukemma.thomas13@wales.nhs.uk (M) 07790 843411