1. 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

2. 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

3. 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

4. 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

5. 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