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The Newcastle upon Tyne Hospitals NHS Foundation Trust Quality Report November 2013
4 5 6 20 13 15 16
Safety Actual 2012/13
Slip, trip and fall - patient (Datix) 2,829 718 691 266 277
Slip, trip and fall - patient (Datix) per 1,000 bed days Not defined 5.3 5.3 5.1 5.9 6.2
Slip, trip and fall - visitor and staff (Datix) 205 46 54 21 19
Sharps and needlestick injuries (Datix) 301 67 87 34 37 37
Inpatients acquiring pressure damage Not available 201 177 48 40 53
Community patients acquiring pressure damage Not available 24 14 2 8 4
Medication: Total number of incidents 1,066 332 304 133 110
Total number of incidents 15,377 4,428 4,337 1,541 1,442Total number of pt incidents reported (Datix) per 100 admissions
5.4 6.5 6.0 6.0 8.0 6.2
Total number of CNST claims (Clinical Negligence Scheme for Trusts)
201 58 15 16
Number of radiation incidents reported to HSE and CQC 16 7 1 1
P t f ti t i id t th t lt d i h
NovemberOctoberSeptember
105
Quarter 1
Not defined
Not defined
Not defined
24
Quarter 2
Not defined
Target 2013/14
6
Not defined
Monthly Target
5.4
288
Not defined
5.4
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
53
12
Not defined
6
222
16
1
17
1,419
Percentage of patient incidents that resulted in severe harm or death
0.85% Not defined Not defined 1.09% 0.88% 0.98%
Never Event 2 3 2 2 0 10
0.97%
0
0.66%
012345678
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Rate of patient fallsper 1,000 bed days2012/13- 2013/14
2012/13 2013/14
Trust Target National Average
0123456789
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Rate of patient incidents per 100 admissions
2012/13- 2013/14
2012/13 2013/14
Trust target National Average
05
10152025303540
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Total number of Sharps & Needlesticks
2012/12- 2013/14
2012/13 2013/14 Trust Target
00.20.40.60.8
11.21.41.6
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Percentage of patient safety incidents that resulted in severe
harm or death2012/13-2013/14
2012/13 2013/14
Page 1
The Newcastle upon Tyne Hospitals NHS Foundation Trust Quality Report November 2013
Serious Untoward Incident (SUI) Actual 2012/13
General 46 100% Ongoing 19
HCAI (Healthcare Acquired Infection) 13 100% Ongoing 3
Information Governance 6 100% Ongoing 0
Never Events Actual 2012/13
Surgical 2
Medication events 0
Mental health 0
General healthcare 0
Maternity 0
0
0
0
0
0
0
0
2
0
0
November
11
October
9
November
2
0
0
0 0
0
0
% response within 60 days
32
Quarter 1
0
Quarter 1Monthly Target
0 0
0 2
0
0
0
0
0
6
0
Quarter 2
3
0
0
0
0
0
October
0
1
0 1
0
Quarter 2
0
% reported within 24hrs
Target 2013/14
0
Details of each SUI reported during November: 12 SUIs were reported to the commissioners in November.
September
7
1
September
Exception Summary:
Never events: There was one never event reported, when a patient undergoing cataract surgery had the wrong strength intraocular lens implanted.
Patient falls: It is dissapointing that the number of incidents relating to patient falls is above target. Work continues across the Trust to embed the Trust Falls Strategy, including further roll out of the falls care bundle and the refreshment and relaunch of the "no falls on my patch" campaign. Pressure ulcers: The number of incidents reporting inpatients acquiring pressure damage has risen in November. It is felt this is due to an increased awareness and drive to report patient safety incidents.Sharps and needlestick incidents: It is disappointing to see that the number of sharps and needlestick incidents has not fallen in November. On review of the last three months reported incidents there has been a rise in the number of medical staff reporting incidents. There has also been a rise in the number of indicents reported by Peri-Operative and Critical Care which is being addressed.
HCAI: One patient died with Clostridium difficile cited on Part 2 of the death certificate.
General: There was one neonatal death.There were two Trust acquired Category IV pressure ulcers.Eight patients fell and sustained fractures.
Page 2
The Newcastle upon Tyne Hospitals NHS Foundation Trust Quality Report November 2013
Clinical Outcomes Actual 2012/13
Summary Hospital-level Mortality Indicator (SHMI) "as expected" 0.94 0.93 0.92
Risk Adjusted Mortality Index (CHKS RAMI 2013) Not defined 95 94
Clinical Effectiveness Actual 2012/13
VTE Assessment Compliance > 95% 95.8% 96.6% 97.2% 98.3% 97.0%
Dementia Assessment Compliance > 90% 90% 91.8% 93.1% 92.3% 93.2% 96.7%
Trust Risk Management (TRM) mandatory training overall compliance levels
Not defined 80% 81.5% 83.5% 83.5% 84.0% 85.3%
NHSLA mandatory training overall compliance levels 79% 82.4% 83.9% 84.0% 84.6% 85.7%
Number of complaints received 626
NICE guidelines (non-compliant) 40 National Confidetial Enquiry into Patient Outcome and Death (NCEPOD) (non-compliant)
4
National Patient Safety Agency (NPSA alerts) (past deadline) 1
National Clinical Audit identified in 2012/13 Quality Account - results awaited
31
Not availableNot defined
Not defined
OctoberQuarter 1Monthly Target
Not available
Target 2013/14 Quarter 2
Not available
Quarter 1
Not defined
Monthly Target
Quarter 2
NovemberSeptember
September November
Not available
Target 2013/14
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
Not defined
"as expected"
Not defined
95%
95%
80%
95%
90%
95%
162 65
53
4
1
13
56
67
4
12
3
2
27
54
1616
2
4
1
October
Not available
176
53
4
2
153
56
results awaited
Exception Summary:
SHMI: An additional report published by the North East Quality Observatory is attached detailing the Trust's most recent mortality rate. The Trust has the lowest mortality rate in the Region. NICE: There were three NICE guidelines reported as non-compliant. These included CG 153 Psoriasis, CG 162 Stroke rehabilitation: long term rehabilitation after stroke and Quality Standard 32 Caesarean Section.National Clincal Audit: The Healthcare Quality Improvement Partnership (HQIP) have published details of the national Heart Failure Audit.
0
20
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120
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chDementia Assessment
Compliance 2012/13-2013/14
8486889092949698
100
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VTE Assessment Compliance
2012/13-2013/14
The SHMI is the ratio between the actual number of patients who die following treatment at the Trust and the number thatwould be expected to die on the basis of average England figures, given the characteristics of the patients treated here.
It covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge.
The graph to the left shows the Trust performance since the SHMI was published against the national average of 1.0.
0.880.9
0.920.940.960.98
11.02
July
10-
July
11
Oct
10-
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11
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11-D
ec 1
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-Mar
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ec 1
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201
2 -M
arch
201
3
SHMI
2012/13 % 2013/14 %2012/13 % 2013/14 % Trust National average
Page 3
The Newcastle upon Tyne Hospitals NHS Foundation Trust Quality Report November 2013
Timely administration of total parental nutrition(TPN) for preterm infants.
Reduce the incidence of preventable severe Acute Kidney Injury (AKI).
CQUIN Indicators - CCG (Community)
Early Warning Score triggering clinical review
Care after deathTo introduce section 3 of the Liverpool Care Pathway (or equivalent) for all deaths- contract variation agreed after the publication of the Independent Review of the LCP
The insertion and management of nasogastric feeding tubes in adult and paediatric inpatients excluding neonates
Friends and Family (see graph below for Trust position)
NHS Safety Thermometer to reduce harm (see graph below for the Trust's October 2013 position)
Dementia Diagnosis in Hospitals
VTE
CQUIN Indicators - CCG (Acute) CQUIN Indicators - North East Specialised Commissioning
All 4 mandatory indicators as per host commissioners (F&F, VTE, Dementia and Safety thermometer)
To continue with and embed the routine use of specialised services clinical dashboards.
Highly specialised services clinical outcome collaborative workshop
Joint scores in severe and moderate haemophilia A and B (patients aged 4 years and over).
( y)
NHS Safety Thermometer to reduce harm
Community quality improvement scheme
Dementia Environment
To increase the number of patients receiving Intraoperative Fluid Management (IOFM)
Exception SummaryQ2 reports were submitted to the commissioners on the 31st of October 2013. The Trust is awaiting confirmation regarding achievement.
93.5094.0094.5095.0095.5096.0096.5097.0097.50
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Safety Thermometer Harm Free Care
November 2012- November 2013
% Harm free care National Target %
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Friends and Family Test Response Rate
2013/14
2013/14 %National Target %Linear (National Target %)
Page 4
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