Nurses Day! - Birmingham Children's Hospital

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As there is not a nationally established and
regulated approach to reporting and categorising
patient safety incidents, different trusts may choose
to apply different approaches and guidance to
reporting, categorisation and validation of patient
safety incidents. The approach taken to determine
the classification of each incident, such as those
‘resulting in severe harm or death’, will often rely on
clinical judgement. This judgement may, acceptably,
Number of patient safety
incidents (acute specialist)
Rate of patient safety
incidents per 100 patient
admissions (acute specialist)
Percentage of such patient
safety incidents that resulted
in severe harm or death
(small acute)
differ between professionals. In addition, the
classification of the impact of an incident may be
subject to a potentially lengthy investigation which
may result in the classification being changed. This
change may not be reported externally and the data
held by a trust may not be the same as that held by
the NRLS. Therefore, it may be difficult to explain
the differences between the data reported by the
Trusts as this may not be comparable.
Oct 2011-March 2012 Oct 2011-March 2012 Oct 2011-March 2012
BCH Highest Trust Lowest Trust
1,370 1,935 66
7.77 12.03 3.36
0.36% 2.36% 0.00%
Birmingham Children’s Hospital NHS Foundation
Trust considers that this number and/or rate is as
described for the following reasons:
Other information
Linking our priorities to the priorities of the NHS
QUALITY
STRAND
Effectiveness
QUALITY DOMAIN
(NHS OUTCOMES FRAMEWORK)
Preventing people from dying
prematurely
Enhancing quality of life
for people with
long-term conditions
Helping people to recover
from episodes of ill health
or following injury
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BCH QUALITY
INDICATOR
Nursing Care Quality Indicators
Asthma Care
Health Promotion
Implementing the Sepsis Care Bundle
Food & nutrition
Nursing Care Quality Indicators
Asthma Care
Health Promotion
Food & nutrition
Nursing Care Quality Indicators
Health Promotion
CAMH Service User satisfaction
Implementing the Sepsis Care Bundle
We are pleased to note the high number of reported
incidents and the low percentage of these that
resulted in severe harm or death compared with the
national average, as this indicates an open safety
culture.
Birmingham Children’s Hospital NHS Foundation
Trust intends to take/has taken the following actions
to improve this number and/or rate, and so the
quality of its services, by:
Patient
Experience
Ensuring that people have
a positive experience of care
Food & nutrition
Play & activities
Emergency department transfers
Tertiary inpatient referrals
Cancelled operations
Friends & Family Test
l Actions we are taking to monitor and improve our
safety culture are described on page 131.
l We investigate and learn from every incident.
l We take actions to address safety issues
identified through safety monitoring and
analysis.
l Safety themes identified through incident
analysis are addressed through safety targets
as part of our Safety Strategy – for example,
extravasation injuries and medication incidents.
Safety
Treating and caring for people
in a safe environment;
and protecting them
from avoidable harm
Pressure ulcers
Reducing Healthcare Acquired Infections in PICU
Reducing rates of C.Difficile
Preventing MRSA
Reducing MRSA
Medication Incidents
Acute life threatening events, Cardiac Arrests
and Respiratory Arrests
Zero avoidable deaths
WHO Safe Surgery checklists
Extravasation injuries