Mortality and harm reduction in Cwm Taf Health Board 25th November 2010 Mortality and harm reduction in Cwm Taf Health Board Insert name of presentation on Master Slide

Mortality Review 100 cases (50 medical, 50 Surgical) Key Findings Appropriate active Management Timely intervention of end of life pathway Appropriate use of DNAR Appropriate use of outreach service / ITU utilisation All medical cases emergency admissions Key Issues No diagnosis / cause of death recorded Evidence of inadequate note keeping Lack of comprehensive coding Top 3 mortality issues Sepsis / infection Fractured neck of femur Cardiovascular deaths / VTE

Global Trigger Tool Key Issues Top Triggers October 2007 - March 2010 624 Case notes 5285 bed days 196 adverse events Key Issues Structure & Quality of record keeping Investigation results not routinely filed in notes Top Triggers Readmission with 30 days Lack of early warning score

Improvements A&E – Safety is everyone’s business Executive support Clear accountability Empowerment Improved relationships Community Hospital – Redesign Director walk round Clinical leadership Patient engagement Suitable environment & Improved observations

Next 12 Months Combine Mortality and Global Trigger Tool (GTT) review sessions GTT Team to include clinical coding Review and act on outcomes Link outcomes to interventions under the 1000 Lives Plus Programme