1. Kupu Taurangi Hauora o Aotearoa

2. Thank you to all people at the pilot sites who contributed Andrea McCance, Caroline Tilah, Cristina Ross, Fran Grocott, Helen Costello, Katherine Foulkes, Mona Pathak, Mo Neville and all others… Thank you to Haelo: Kurt Bramfitt and Lyn McIntyre

3. NHS Safety Thermometer Measure 4 harms ‘harm-free care’ – Pressure injury – Falls and falls with harm – Catheters and UTI – VTE Audit of at least 10 patients/week in district nursing or ward 366 patients tested, 77% DN, 33% ward

4. Patients submitted Week12345678910Total CCDHB 10 142120 135 N’land 109 9 6 1126111 Waikato 292716151716120 Total 4946363437322431 46366 Age and ethnicityMāoriPacificAsianOtherTotal <18336 18-5416513052 55-698477291 >702061190217

5. Pressure injury Record the patient’s WORST old pressure injury and WORST new pressure injury. An ‘old’ pressure injury is defined as being a pressure injury that was present when the patient came under your care, or developed within 72 hours of admission to your organisation. A ‘new’ pressure injury is defined as being a pressure injury that developed 72 hours or more after the patient was admitted to your organisation. Where a patient has an old pressure injury which has got worse in your care this would be considered a new pressure injury. Pressure injuries cannot be downgraded, only fully healed

6. Falls Record the severity of any fall that the patient has experienced within the previous 72 hours in a care setting (including home if the patient is on a district nursing caseload). A fall is defined as an unplanned or unintentional descent to the floor, with or without injury, regardless of cause (slip, trip, fall from a bed or chair, whether assisted or unassisted). Patients ‘found on the floor’ should be assumed as having fallen, unless confirmed as an intentional act.

7. Catheters and UTI Record information about any urinary tract infection (UTI) treatment and urinary catheterisation. Treatment for a UTI is based on notes, clinical judgment and patient feedback If the patient is being treated for a UTI, record whether the treatment started before the patient came was admitted to your organisation (old) or after the patient was admitted to your organisation (new). If treatment for or diagnosis of the UTI started before the patient was admitted to your organisation, select ‘Old UTI’ from If the treatment for the UTI started whilst the patient was under your care, select ‘New UTI’

8. Venous thromboembolism VTE risk assessment -record whether or not a patient has a documented risk assessment for VTE. This information is required for all surveyed patients. There are three options for recording this information on the drop down menu: Yes, No and N/A. If the patient has a documented risk assessment for VTE then select, ‘Yes’, if not, select ‘No’. If the question is not appropriate for the patient or setting, select ‘N/A’.

9. Pressure injury % patients with any: 10.4% Old: 7.1% – Present on admit or within 72 h New: 3.3% – Not present on admit or developed within 72 h OldNew Stage 2197 Stage 342 Stage 433 Total2612

10. VTE Risk assessment: – Yes, No, NA (if no tool) More patients received prophylaxis than were assessed – documentation? DVT: 1 new, 1 old PE: 2 old VTERAProphylaxis NA101170 No254161 Yes1135

11. Falls with harm % patients with fall in previous 72 h: 5.7% Harm: Low: first aid, minor treatment, extra observation or medication Moderate: outpatient treatment, admission, surgery or increase LOS Severe: permanent harm, brain damage or disability Falls No fall345 Fall21 No harm10 Low harm9 Moderate harm2

12. UTI & catheter Catheter and any UTI: 1.6% Any UTI and no catheter: 3.8% No catheterCatheter New UTI63 Old UTI83 No UTI31036 Total32442

13. All DHBs ‘harmfree’ care

14. Survey monkey 1.13 people completed – 5 from hospital ward – 7 from community district nursing service – 1 unknown 2. On average, how long did it take to complete the 'Classic' Safety Thermometer per patient ? Under 5 minutes46% (6) 6 - 10 minutes23% (3) 11 - 15 minutes23% (3) 16 – 20 minutes8% (1)

15. Relevance and ease Not at all relevant15% (2) Relevant to some extent69% (9) Extremely relevant15% (2) 3. Overall, how relevant do you feel the 'Classic' Safety Thermometer is to your organisation? 4. Overall, how would you rate the 'Classic' Safety Thermometer's ease of use? Very simple to use273% (3) Fairly simple to use69% (7) Not simple to use8% (1)

16. Method and Method for data collection: Notes 0% (0) Conversation w patient 8% (1) Patient assessment 15% (2) All 77% (10) Would you recommend to a colleague? Yes - 46% (6) No - 54% (7)

17. Rate the usefulness of each harm (%) Very usefulSomewhat usefulNot useful PI50428 Falls with harm50428 UTI5025 Catheter581625 VTE172558

18. Comments Could see the benefit in some of the inpatient areas particularly longer stay wards. PI – include all, stage 1 Falls within 72 h is limited UTI without catheter unnecessary? Catheter and UTI useful but not immed post-op VTE – NA is no risk assessment is problematic Pressure areas occur prior to coming onto our service whether from community or hospital and the reason we are visiting is for wound care. Time spent with patients useful to promote health, but not all harms relevant for all patients

19. Summary PI most commonly reported harm Query value of VTE (risk assessment tool and documentation gap)? Definitions need refining for NZ District nursing value add? (older pts?) Consistency in data collection method is vital

20. Pressure injury National PI surveillance, lack of national data – could this method be adapted? If already collecting, agree a definition and method? – eg: old versus new (72 hour cutoff) Include category 1 Link to contributory measures eg, LOS, patients experience or new one - harmfree care?

21. All DHBs ‘harmfree’ care