1. Workstream Leads: Hester Wain, Emma Vaux, Alison Huggett Reducing Needless Harm and Death To reduce the rate of preventable harm by 50% by 2015, as measured by monthly Trigger Tool reviews To reduce avoidable deaths by 10% by 2011, as measured by bi- annual mortality reviews To identify themes from both reviews and use these to implement quality improvement initiatives that can be disseminated

2. CoG briefing paper on Qacc feb11.doc Author: Hester Wain PhD Page 1 of 2

3. What do we do? Use Trigger Tool (TT) and systematic mortality case note reviews to identify harm and avoidable death Trigger Tools for the community, paediatrics and obstetrics introduced for development A structured Mortality Review Template (MRT) has been developed to enable identification of avoidable death The themes identified are used to target action plans and the development of innovative practice For the mortality reviews the work has concentrated on the acute sector to date

4. The Learning Process: Need for dedicated lead, time commitment, consultant engagement, commitment to transparency, feedback of learning Outcome: Themes have been identified and shared to enable targeted innovative practices. Examples include: Extended scenario ILS (Immediate Life Support) programme for all junior and senior doctors to target recognition of the sick patient AKI (acute kidney injury) care bundle Hospital associated pneumonia Quality Improvement Project Review of Early Warning System Introduction of electronic handover tool

5. Achievements to date Baseline Trigger Tool figures achieved in 6/8 Acute Trusts Systematic Mortality Review in 7/8 Acute Trusts Participation of 18 Trusts in the workstream Mortality Review Template (MRT) for General Practice, Community Hospitals and SCAS in Pilot Successful integration of Reducing needless harm and Reducing needless death workstreams

6. Moving forward to make a difference Embed the process - case note reviews across all the SHA sectors Progress the actions: Move forward with identifying and sharing initiatives to address the resulting themes, to make a difference in practice and reduce avoidable harm and death Patient involvement: patient representatives have been identified Junior doctor involvement: a junior doctor representative has been identified

7. Key Messages 1.Our focus is quality improvement, driving learning and development 2.Benchmark your results against yourself and not others 3.This work requires commitment from the Trust Board to the frontline

8. Your Challenge Do you know the outcomes of your case note reviews? What initiatives are targeted to reducing harm and death for your patients? How do you know these initiatives are working?

9. Acknowledgements Becky De’Ath (Workstream Project Manager) Janie Penny (PSF Administrator) Patient Safety Federation Participating trusts: Basingstoke and North Hampshire Foundation Trust, Berkshire East PCT, Berkshire West PCT, Buckinghamshire Hospitals NHS Trust, Hampshire Community Health Care, Heatherwood and Wexham Park Hospitals NHS Foundation Trust, Isle of Wight NHS, Milton Keynes Hospital NHS Foundation Trust, Nuffield Orthopaedic Centre NHS trust, Oxford Radcliffe Hospitals NHS Trust, Oxfordshire PCT, Portsmouth Hospitals NHS Trust, Royal Berkshire NHS Foundation Trust, South Central Ambulance Trust, Southampton University Hospitals NHS Trust, Winchester and Eastleigh Healthcare NHS Trust, Solent Healthcare, Buckinghamshire PCT.