Patient Falls Metric (2018) Falls Unintentionally coming to rest on the ground, floor or other lower surface (NPSA 2010) Include all slips, trips and falls e.g. if a patient is found on the floor, lowered themselves onto the floor, slipped from a chair, rolled out of bed, etc. Figures required for each fall per degree of harm. The 'level of harm' must be allocated within 48 hours of when the incident happened. No Harm Any patient safety incident that ran to completion but no harm occurred How this might relate to your IPU Patient found on the floor with no signs of injuries and is able to explain why they are there. No additional observations taken other than routine nursing checks. Low Harm Harm requiring first aid level treatment or extra observation only (e.g. bruises, grazes). Any patient safety incident that required extra observation or minor treatment and caused minimal harm, to one or more persons receiving care. How this might relate to your IPU A patient who has bruising and grazes and only requires first aid and/or additional observation.
Moderate Harm Severe Harm Death Harm requiring hospital treatment or a prolonged length of stay but from which a full recovery is expected (e.g. fractured clavicle, laceration requiring suturing). Any patient safety incident that resulted in a moderate increase in treatment and which caused significant but not permanent harm, to one or more persons receiving care. How this might relate to your IPU A patient whose injuries resulting from the fall requires a visit to A & E for investigation. They may not need a hospital stay. This would also include patients where a decision is made not to transfer someone to A & E if very near end of life and further investigation may not change the management. Harm causing permanent disability (e.g. brain injury, hip fractures where the patient is unlikely to regain their former level of independence). Any patient safety incident that appears to have resulted in permanent harm to one or more persons receiving care. Where death is directly attributable to the fall References - National Patient Safety Agency 2010 Slips trips and falls data update NPSA: 23 June 2010. - NPSA Seven Steps to Patient Safety.
Pressure Ulcer metric (2018) Pressure Ulcers Include each pressure ulcer only ONCE. Count the number of Pressure Ulcers and NOT the number of patients. Include ONLY hospice acquired pressure ulcers, grade 1 and above and also capture if they were avoidable /unavoidable. The PU is recorded only once over the episode of care. This will be at the end of that phase of care when the patient has been discharged or died (e.g. If the patient has been in your care in Q1 and dies in Q2, it is recorded only in Q2 at the grade it was at that end of care phase). Use the EPUAP classification system in the reference below. Admitted with /inherited 1. The patient is admitted onto the IPU with a pressure ulcer from any care setting (e.g. home, care home, and hospital). 2. If the patient is assessed on admission and found to have suspected deep tissue injury (SDTI). When the SDTI re-assessed at any point and found to have become a PU this is to be graded and recorded as admitted with/ inherited. 3. For the purpose of this benchmarking we are NOT capturing inherited PU s regardless of length of stay or whether it improves or deteriorates Acquired The patient develops a pressure ulcer whilst on the IPU which was NOT present on admission.
Of the Acquired Pressure Ulcers, are they a/n: Avoidable Pressure Ulcer The person receiving care developed a pressure ulcer and the provider of care did not do all of the following: 1. Assess and evaluate the person s clinical condition and pressure ulcer risk factors. 2. Plan and implement interventions that are consistent with the person s needs, goals and recognised standards of practice. 3. Monitor and re-evaluate the impact of the interventions 4. Revise the interventions as appropriate. 5. Record findings and intervention. Unavoidable Pressure Ulcer The person receiving care developed a pressure ulcer even though the provider of the care had completed and recorded the following: 1. Assessed and evaluated the person s clinical condition and pressure ulcer risk factors 2. Planned and implemented interventions that are consistent with the person s needs, goals and recognised standards of practice 3. Monitored and re-evaluated the impact of the interventions within the time frame of the local practice guidelines 4. Revised the interventions as appropriate; or the individual person refused to adhere to prevention strategies in spite of education of the consequences of non-adherence1 References Prevention and Treatment of Pressure Ulcers EPUAP 2014 http://www.tissueviabilityscotland.org/downloads/epuap%20gradin g%20tool.pdf)
Medication Incidences Metric (2018) Medication Incidents Please review your incident reporting records to ascertain level of harm identified Safety in doses; improving the use of medicines in the NHS, National Patient Safety Agency, National Reporting and Learning Service (2009) Medication errors are any incident where there has been an error in the process of prescribing, dispensing, preparing, administration, monitoring or providing medicines advice, regardless of whether any harm occurred or was possible This is a broad definition and most errors result in no or low harm. Please note for the purpose of this benchmarking programme the focus is ONLY on patient harm. Medicines and Healthcare Products Regulatory Agency (MHRA) Patient Safety Alert improving medication error incident reporting and learning (2014) Medication errors are Patient Safety Incidents (PSI). These PSI s can be divided into two categories; errors of commission or errors of omission. The former include wrong medicine, wrong dose. The latter include an omitted dose or a failure to monitor. Medical Error National Patient Safety Agency (2010) Collect from level 0 Level 0 No harm; incident prevented Incident prevented near miss (the incident did not cause harm to the patient but was judged to have the potential to cause harm) Level 1 No harm; incident not prevented For example: wrong dose prescribed but noticed before dose given to patient Incident occurred - but no harm was caused to the patient For example: wrong dose given or dose missed but no adverse affect on patient.
Level 2 Low harm Any incident that required extra observation or minor treatment (but there was no change in the clinical status) For example: Opioid dose given too high and required observations and but no adverse affect on patient Level 3 Moderate harm Any incident that resulted in a moderate increase in treatment/laboratory monitoring (change to the clinical status), but not permanent harm to the patient For example: Opioid dose given too high and patient became opioid toxic requiring naloxone Level 4 Severe harm Any incident that appears to have resulted in permanent harm to the patient Level 5 Death Any incident that has directly resulted in the death of the patient Please consider if the Duty of Candour may apply