Reducing Mortality & Harm 25th November 2010 Reducing Mortality & Harm Dr Simon Mahon, Medical Director, Hywel Dda Health Board

Reducing Harm & Mortality in Hywel Dda Health Board Main Actions Since April 2010, 1099 deaths within secondary care in the Health Board (97.2%) have been reviewed by senior medical clinicians. All coding has been clinically verified in conjunction with coders.   Any concerns raised have resulted in a more in depth audit and follow up. However only 20 (1.87%) have had significant concerns raised. Follow up consists of cascading lessons to be learned via morbidity / mortality / audit meetings and a Health Safety Bulletin GTT (20 sets each acute hospital monthly) running since May 2010 Our adverse event rate is currently running below our target of 27.18 Since January 2010 our RAMI has dropped from 128 to 82 in July 2010 (it has been as low as 80) Reducing Harm & Mortality in Hywel Dda Health Board

Reducing Harm & Mortality in Hywel Dda Health Board Focus on 3 Key Areas Infection Rate Reduction 100% ITU bundles √ Big Brother is Washing You! √ Poster Campaign √ Burden Identified (ECDC Prevalence Tool) √ Rapid Response for sick patients / failure to rescue M E T’s √ RAILS integrated into existing committee structure √ Track and Trigger 3 counties (VIEWS) √ Multidisciplinary ACDU WGH √ Communication 1000 lives Leadership Group √ Walkarounds √ Legibility notes GTT and Mortality Review √ WHO Checklist preventing harm √ Reducing Harm & Mortality in Hywel Dda Health Board