Agenda and supporting papers - Plymouth Hospitals NHS Trust

Item 8
The Trust uses the IHI Global Trigger Tool methodology to conduct retrospective reviews of
patient records using ‘triggers’ to identify possible adverse events. A clinical team review 20
sets of patient notes per month. The graph indicates that from March onwards the majority of
the data points were below the 15% mean. The mean and upper control limits have been
recalculated accordingly.
4.6 Hospital Acquired Pressure Ulcers (Datix)
The Trust target is a 50% reduction in grade 3 and grade 4 hospital acquired pressure ulcers
per month using the P2 measure on National Safety Thermometer
At the Safe Care Group meeting in May 2013 the group reviewed the frequency in
occurrence of hospital acquired pressure ulcers (HAPU) (grade 3 and 4) and agreed that
hospital acquired pressure ulcers would be monitored monthly by the group. It was also
agreed that the current plan to reduce the numbers of HAPU would be reviewed and an
improvement programme implemented to reduce the frequency in line with the CQUIN plan
for 2013/2014.
4.7 Inpatient Falls (Datix)
200
Number of Reported Patient Falls (Datix)
by Month and Severity
180
160
140
120
100
80
60
40
20
0
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Mar‐13
Apr‐13
May‐13
None Minor Moderate Severe/Catastrophic Death caused by the incident
7