Programme

Falls Prevention & Reduction

What are we trying to do?

To implement Trust wide strategies to prevent patient falls and to reduce the numbers of falls, and the harm arising from falls.

How will we know that a change is an improvement?

Achieve a 10% reduction in level 4 & 5 falls. (Falls which result in, or have the potential to result in the most harm).

What changes can we make that will result in improvement?

We have implemented a Slip, Trips & Falls Policy which is audited bi-annually.

Established weekly key performance indicator (KPI) meetings to review every fall.

Level 4 & 5 severity falls undergo root cause analysis is carried out on all level 4 & 5 falls and actions arising are reported to the Falls Steering Group.

Programme

Reducing High Risk Medication Errors

What are we trying to do?

To reduce the incidence of errors across a range of high risk medications, including anticoagulants, penicillin, insulin, opiates and ten-fold errors.

How will we know that a change is an improvement?

A reduction in the number of events as demonstrated by the Medicines Safety Dashboard.

No ten-fold errors as demonstrated by the Medicines Safety Dashboard.

What changes can we make that will result in improvement?

Developing and implementing of an e-learning package “calculating drug doses for children”.

Developing Safety Action Reports in response to frequent medication incidents. Timely responses to National Patient Safety Agency alerts.

Programme

Recognising & Responding to the Acutely Unwell Adult

What are we trying to do?

To ensure that the acutely unwell patient is appropriately monitored and deterioration is managed in line with the Trust's Early Warning Score Policy.

Avoidable cardiac arrests are identified.

Admission to Intensive/High Dependency Care Unit due to unrecognised deterioration is reduced.

How will we know that a change is an improvement?

% improvement in compliance with Trust's Observation and Early Warning Score (EWS) polices from 94% to 99%.

To develop baseline measure of avoidable cardiac arrest.

To develop baseline measure of unrecognised deterioration.

What changes can we make that will result in improvement?

Undertaking annual audit of Trust Observation & EWS policies.

Procuring and implementing of an electronic bedside observation and recording system.

Establishment of emergency bleep case review meetings which seek to understand the antecedents to the instigation of an emergency call. It is anticipated that the learning from these meetings will inform the baseline measurements for improvement.

Programme

Reducing the Prevalence of Hospital Acquired Pressure Ulcers

What are we trying to do?

To identify the source of all pressure ulcers across the Trust (hospital or community).

To establish a 20% reduction in grade 1 and 2 hospital acquired pressure ulcers.

To have no hospital acquired pressure ulcers (grade 3 or above).

How will we know that a change is an improvement?

100% compliance with risk assessment (waterlow score). Baseline and ongoing data to be captured through Matron Walk Rounds.

20% reduction in reduction in grade 1 & 2 hospital acquired pressure ulcers once baseline established. No grade 3 or above hospital acquired pressure ulcers. (Pressure ulcers are graded 1 to 4 with 4 most being the most severe).

What changes can we make that will result in improvement?

Work is currently being undertaken to establish baseline in terms of incidence of hospital acquired pressure ulcers.

A Trust wide point prevalence audit undertaken (including paediatrics for first time) which demonstrates a rise in incidence from 5% 2008 to 7% 2009.

A steering group has been established and meets on a monthly basis to review and develop assurance and monitoring framework.

Weekly case review meetings commenced in September 2009 at which all incidents of pressure ulcers are reviewed and lessons learnt/key actions agreed.

Implemented an Integrated Care Pathway for patients identified at risk of pressure ulcer development.

All pressure ulcers recorded via Trust incident reporting system.