Annual Report and Accounts - The Great Western Hospital

CHART - Relative risk SW Acute Trusts April 2011 – February 2012
120.0
100.0
80.0
60.0
40.0
20.0
Relative Risk SW Acutes April 11- February 2012
0.0
RR
The Trust has an established Trust Mortality Group that meets on a monthly basis and includes
clinician representation from each Clinical Directorate as well as representatives from Quality, Clinical
Audit, Risk, Informatics and Clinical Coding. The work of this group includes monthly reports on
mortality produced by the information department and centred on Dr Foster tools. Red bell alerts
from Dr Foster are investigated with review of coding and clinical care. CUSUM reports also
produced by Dr Foster are being used to identify areas for proactive investigation where mortality
appears to be increasing prior to a red bell alert. This tool has also been introduced to monitor areas
which have previously alerted to give assurance that improved performance is maintained. Audits
have been presented back to the Patient Safety and Quality Committee. Action plans arising from
these audits which have the potential to improve patient care, reduce the risk of preventable deaths.
Further information is contained in the Quality Account 2011/12.
Clinical Incidents – Never Events, Serious Incidents and Incidents
Never Events: A total of three never events have been recorded in the Trust between April 2011 to
March 2012. All three were surrounding surgery;
1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post-operation
Serious Incidents: All serious incidents are investigated to identify the care and service delivery
problems which contributed to the root cause of the incident. These are addressed in an action plan
which is then communicated within Directorate meetings and reports across the Trust to ensure
learning is shared. 71 serious incidents were reported and investigated across the merged Trust
during the period April 2011 to March 2012. This was a decrease from the previous year April 2010
to March 2011 of 100 (44 GWH and 56 WCHS incidents added to quantify the figures). The graph
below demonstrates the number of Serious Incidents grouped by type of incident.
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