1. Mortality and harm reduction in Cardiff and Vale UHB
25th November 2010
Mortality and harm reduction in Cardiff and Vale UHB

2. Driver Diagram WalkRounds/Patient Safety Fridays Leadership for QI
Mortality & Harm Reviews
Build Skills Capacity & Capability
Ventilator acquired Pneumonias
Ventilator bundle
Clostridium Dificile
Clostridium Dificile Bundle
Blood stream infections
Central & Peripheral Line Insertion & Maintenance Bundles
Hospital Acquired Infections
Catheter Associated UTI
Urine Catheter insertion & maintenance bundles
Surgical site infections
Sepsis/RRAILS
Early Warning Scores & Rapid Response
SSI Bundle
Reduce Mortality, Harm, Variation and Waste
Surgical Errors
WHO Checklist
VTEs
HAT assessment, prevention and treatment
Medicines Management
Reconciliation
First episode psychosis
Mental Health
High risk medications
Depression
Pathways and Bundles
Dementia
Heart Failure
Stroke care
Falls Prevention
Pressure Ulcers
SKIN Bundle
Transforming Care

3. C-dificile actions C-dif group established UHB action plan in place
All divisions have an action plan
Antibiotic sticker developed to guide the process and make adherence more intuitive
Organisation – wide antibiotic stewardship – cefuroxime and ciprofloxin prescribing ceased on 1st June 2010
Audit/measurement tool developed. First audit completed – awaiting results – great variation in practice at present.

4. Mortality Audit Weekly Deaths Review Group established
Led by Medical Director, supported by Assistant Medical Directors (x2); Assistant Director Patient Safety & Quality; Improvement Advisor and Clinical Audit Manager
Data extracts generated weekly via Clinical Governance Data Analyst from CHKS, patients whose RAMI suggests least likely to die (RAMI less than 0.25)
On average 18 of 45 weekly deaths case notes reviewed
If triggers identified Medical Director generates letter for lead Consultant to undertake case review and feedback
Key learning to date
Coding Quality improving
Raising the profile and importance of clinical coding with clinicians and making some operational changes to working arrangements to strengthen coder / clinician interface.
Awareness of other mortality data surveys