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%

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Rate of patient fallsper 1,000 bed days2012/13- 2013/14

2012/13 2013/14

Trust Target National Average

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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

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2

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0

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11

October

9

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0

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0 0

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% response within 60 days

32

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0 0

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% 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.

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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.

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Compliance 2012/13-2013/14

8486889092949698

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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

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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 %)

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