Annual Report and Accounts 2012/13 - Royal Devon & Exeter Hospital

2. Progress on our
2012/13 Priorities
Royal Devon and Exeter NHS Foundation Trust
Quality Report 2012/13
23
CASE STUDY
Patient Safety Thermometer
The NHS safety thermometer is a tool
developed and implemented nationally
to measure ‘Harm Free Care’. ‘Harm
free care’ is defined as the absence of
four ‘harms’:
• Pressure ulcers
• Patient falls
• Urinary tract infections in patients
with a catheter
• New venous thromboembolism
(blood clots).
The NHS is striving to provide ‘harm
free care’ as these harms affect over
200,000 people each year in England
alone, leading to avoidable suffering
and additional treatment for patients
and a cost to the NHS of more than
£400million.
The Royal Devon and Exeter has
extensive programmes of work tailored
to each area to prevent these harms
occurring to patients and has seen
improvement in each one. On a single
day each month, every patient in our
care is reviewed by a matron or other
senior nurse to identify if any of these
harms have occurred at any point in
their care. These spot audits provide
our nursing leaders with a really good
insight into the everyday standards of
care across their wards.
Some patients may have already come
to harm before they arrived at the
RD&E, for example they may have
acquired a pressure ulcer at home or
in another care setting. We therefore
measure two indicators: ‘harm-free
care’ for patients across their whole
NHS journey, and ‘absence of new
harm’ for patients directly in our care.
Each month’s figures are reported
to the Board in the ‘Ward to Board’
report. They also act as an additional
cross-check on our existing reporting
procedures.
Our overall performance for 2012/13
was:
• 95% harm-free care
• 97% no new harm.
Senior Matron, Anita Irwin, explains
the difference that the safety
thermometer has made – for patients
and staff:
“We’ve been running the safety
thermometer programme for a year
now and have found it’s a really useful
addition to our care quality and safety
toolkit.
“It’s my role to co-ordinate the safety
thermometer each month. On the
second Tuesday of every month, I visit
every area of the Trust, carrying out
the audit and supporting the matrons
in completing their database. If they
are reporting anyone with one of the
four harms, I’ll validate the information
– and we’ll also discuss whether
any further action is necessary. For
example, we’ll ask the tissue viability
nurses to review patients with pressure
ulcers."
“The safety thermometer provides
me with an opportunity to meet
with all the matrons across the Trust.
Their enthusiasm for the 'Safety
Thermometer' is amazing. It enables
them to focus their attention on a
particular element of care on their
ward, and to visit and talk to every
patient in their care.
“The feedback from staff has been
overwhelmingly positive and patients
appreciate the time they get with a
matron. As well as increasing our focus
on safety, I think it’s enhanced our
ward communication and leadership
capacity.”