The NHS Safety Thermometer10 Steps to Success Series!

Understanding how we measure harm in healthcare

Step 1

‘It may seem a strange principle to enunciate as the very first requirement in a hospital

that it should do the sick no harm’

Florence Nightingale, 1859.

Hospitals are only an intermediate stage of civilisation

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

Source; Ovretveit 2009

Adverse events – what’s the global picture?

• ”Failure to rescue”• DVT/pulmonary embolism • Pressure (decubitus) ulcers, falls etc

Most estimate 30-50% preventable

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)

The NHS is data rich…….

Measuring Harm

In reality it is probably measured like this based on preference…….

Adverse Incident Reports

Case note review

Point of care

Lab dataTrigger tools

Unpacking sources of dataIncident Reporting

Incident Reportin

g Administrative Data

Point of Care Survey

s

Case Note

Review

Administrative Data

Incident Reportin

g

Administrative Data

Point of Care Survey

s

Case Note

Review

Point of care surveys

Incident Reportin

g

Administrative Data

Point of Care Survey

s

Case Note

Review

Maybe the solution lies with using multiple sources of data for a single

issue?

Triangulation – pressure ulcer exampleResearch Admin

DataAdverse Event Safety

ThermometerAudit

Pressure Ulcers 7%

prevalence(category II-IV)

0.3% prevalence(all categories)

383

Reports each year

8.2% prevalence(category II-IV)

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 assuranceteam – what will you tell the Board?