REDUCING NEEDLESS HARM AND DEATH WORKSTREAM

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REDUCING NEEDLESS HARM AND DEATH WORKSTREAM
How Trusts participating in the Workstream have
benefitted
What Trusts have done differently from it's
participation in the PSF (or workstream
specifically) From participating in the PSF
we have a full programme of patient safety
campaigns across the year which cover all
elements of patient safety. This campaign
programme has been modified for the forthcoming
year to include even more with most months now
having two themes.  We cover all the PSF
workstreams plus patient experience, discharge
process, advanced care planning, normal birth,
dementia, incident reporting etc We are in
the process of setting up regular monthly
mortality reviews but have continued to review
hospital deaths more thoroughly on a weekly
basis, and the Medical Director reviews these on
a monthly basis (or sooner if necessary) A
sub-group of the Patient Safety Committee has
been set up to review documentation standards and
the physical state of the patient notes. This is
specifically related to the finding in the
Mortality Review in April 2011. However through
the above initiatives we have seen an increase in
awareness and use of the RSVP Communication Tool
which was confirmed by an audit in Nov 2011. From
this we expect to see an improvement in response
to deteriorating patient Following our
participation in the PSF mortality review
programme we have continued to conduct a
programme of mortality reviews which take place
every six months.  A report complete with
recommendations and an action plan is compiled
following each review.  The report is presented
and discussed at the Risk Monitoring Group which
has representation from all Divisions with
summary information provided to the Healthcare
Governance Committee
Trusts have used the funding received from the
Patient Safety Federation for the Mortality and
Trigger Tool Reviews in the following
ways. The Trust used the funding to backfill
a consultant to undertake the initial mortality
review.  The Trust now reviews all deaths on a
weekly basis (done on a ward by ward basis by the
relevant teams).  All unexpected deaths have a
more detailed review to identify triggers and
possible iatrogenic harm. Themes are then shared
in the divisional M M meetings and at academic
half day meetings We have used the funding
to support running more Mortality Trigger Tool
Reviews and have utilised some of the funding to
support staff to be released to undertake this
work   The funding enabled us to carry out the
Mortality and Trigger Tool Reviews by covering
the costs incurred. We have also used the
funding to increase the use of the RSVP
(Reason-Story-Vital Signs-Plan system)
Communication Tool to enhance communication of
the deteriorating patient, by placing A6
laminates of the RSVP Tool by every telephone in
clinical areas