Step 1 The NHS Safety Thermometer 10 Steps to Success Series! Understanding how we measure harm in healthcare Welcome to this recording on the NHS Safety Thermometer. If you want to see more clearly on the right you can close the participants and table of contents boxes. If you want to My name is Maxine Power, I am………. Before we go in to the Safety Thermometer, we re going to start by thinking about how we measure harm.

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

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 Most international studies carried out in the US, Australia, Europe and the UK, find safety incidents sufficient to prolong hospital stay in around 10% of admissions (range 4-17%)  Preventability is estimated at 30-50% but is very subjective The big categories of safety incident are medication errors (around 30%), infections (around 15%), related to surgery or procedures (30%) and related to ongoing care (25%) There has been no appreciable change over the 10+ years of patient safety work Do we want a slide for lessons from mid staffs? ”Failure to rescue” DVT/pulmonary embolism Pressure (decubitus) ulcers, falls etc Source; Ovretveit 2009

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) 14,537,958 admissions 5.7% 5.7% All harm 1.2% Mod to Severe 0.4% Fatal This slide focuses on incident reporting through the NPSA which as we discussed in the last slide is believed to be underreported, only detecting 10-20% of harm The data is taken from the NPSA website (the latest report) and proportions have been calculated using the number of admissions each year 14,537,958 (elective & non-elective). This is why we have only used incidents in acute care. Kate Cheema made the calculations so please contact her if you have any questions or want further details of the calculations: katherine.cheema@southeastcoast.nhs.uk Key questions to raise Where is the boundary between unsafe care and inevitable side effects of treatment"?  "Is it legitimate to say some things should never happen? ...and others are inevitable?" "Are there things which we used to think of as inevitable but we now recognise as avoidable"?

The NHS is data rich……. Complaints Audit data Adverse incident reporting Productive ward data Risk assessments Safety Cross Performance data There are many different sources of data in the NHS. Each source has it’s own unique characteristics but also overlaps with others. Whilst working with many organisations whilst developing the safety thermometer we realised that this can sometimes become a confusing picture and we have been working with teams to help try to understand the many different measurement systems and how we can make sense of the different harm data each of them can give us.

Measuring Harm Incident Reporting Point of Care Surveys Adverse Events NRLS Complaints / PALS Administrative Data HES Risk adjusted HSMR Readmissions LOS Point of Care Surveys NHS Safety Thermometer Local Audits Safety Cross Case Note Review Global Trigger Tool National Audits This image is the first step in us understanding each of the different measurement systems. I should remind you at this point that we are primarily focussing on the four harms that the safety thermometer measures, pressure ulcers, falls, urinary tract infections in patients with a catheter and new VTE. As you can see we have four categories: administrative data, point of care surveys, case note review and incident reporting. Talk through each. Administrative data – very important but as yet underreported for the four harms we are looking at Adverse Events – vital information on more sever harms, category 3 and 4 pressure ulcers and serious harm from falls etc. Important information gathered through route cause analysis but data is not timely. Case Note Review – again very important source of data. Audits can be used to gather large amounts of information which can identify areas for improvement and help us understand how patients are harmed. GTT ……. Point of care surveys: Again another different but very important source of information. Quick and easy to collect, part of patient care, clinical staff collecting data, snap shots of information in real time…….

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

Unpacking sources of data Incident Reporting Advantages entity Known Falls PU & Challenges Time ++ Report Staff Incident Reporting Administrative Data Case Note Review Point of Care Surveys

Code available for PU & falls Administrative Data Advantages Automated Code available for PU & falls Challenges Variation Coding report Under Incident Reporting Administrative Data Point of Care Surveys Case Note Review

Point of care surveys Case Note Review Point of Care Surveys Advantages Harm ‘free’ Composite Data & charts immediate Challenges Sample Size Consistency Use???? of Incident Reporting Administrative Data Case Note Review Point of Care Surveys

Maybe the solution lies with using multiple sources of data for a single issue? 2 1 3 Perfect Safety Measurement?

Triangulation – pressure ulcer example Research Admin Data Adverse Event Safety Thermometer Audit Pressure Ulcers 7% prevalence (category II-IV) 0.3% (all categories) 383 Reports each year 8.2% 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 assurance team – what will you tell the Board?