Quality Account 2010/11 - James Paget University Hospitals

Metric 6 – Mortality and Case Note Reviews (using Global Trigger Tool)
50% of harm events are thought to be avoidable (NPSA 2007). The use of triggers to identify
adverse events during a manual record review has been used extensively to measure the
overall level of harm in health care organisations.
Local Improvement Aims:
1. 100 baseline random mortality reviews to be completed by end March 2010.
2. 40 baseline random case note reviews (harm events) to be completed by end March
2010.
3. 20 random mortality reviews to be completed every month from April 2010 onwards.
4. 20 random non mortality case note reviews to be completed every month from April 2010
onwards.
Successes:
• Excellent learning opportunities identified
• Highlighted trends that are being incorporated into improvement projects e.g. delays in
appropriate escalation of concerning patients, poor fluid management and completion of
fluid charts, poor clinical record keeping
Concerns:
• Medical capacity to commit to review process
• Overlap with existing mortality review groups
• Timely administrative process to arrange reviews.
Metric 7 – Medicines Management
Between September 2006 and June 2009 27 deaths, 68 severe harms and 21,383 other
patient safety medicines incidents were reported to the NPSA nationally.
Local Improvement Aim:
1. Ensure reasons for drug admissions are appropriately documented on the drug chart
2. Improve pain management processes and patient outcomes
3. To evidence other medicines management actions required from adverse event trends.
Successes:
• Multidisciplinary focus
• Working on the principle of 7 key responsibilities for medicines management
• Working directly with Medicines Management Action Group.
Concerns:
Although progress has been made there is room for further improvements. As a result
medicines management will have a more targeted focus in the forthcoming year to identify
ideas and innovations and how we can make more of a difference.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2010/11 Page 37 of 62