1. The NHS Safety Thermometer 10 Steps to Success Series! Why are we focussing on these four harms? Before we start…….

2. Pressure ulcers Falls Urinary infections (in patients with catheters) VTE The NHS Safety Thermometer

3. Every year in England 67,848 patients are reported as having a pressure ulcer (category III&IV) like these Pressure Ulcers “The pain I suffered was immense, it was hard to move and yet I was told that was the best thing to do.” “I couldn’t feel the pain as I have no feeling in my legs, but in some respects that was worse. I could see this horrible wound and yet felt nothing.” 70% of pressure ulcers are category IIs

4. Urinary infection in patients with a catheter Every year in England there are 74,689 patients with catheters & infection “I feel like my insides are swollen and going to pop” “a painful, burning feeling” “a terrible fever, sweating and uncomfortable”

5. Falls Every year in England there are 65,760 patient falls (with harm) reported “after my fall I was scared to get out of bed or even reach for my drink” “I was in hospital for another 3 weeks after I fractured my hip”

6. It is estimated that 25,000 people who are admitted to hospital die from preventable VTE each year (NICE 04 TH March 2011) VTE “my hobby used to be walking…but I can no longer walk for more than a few minutes. My life is not the same anymore” “I was terrified”

7. Pressure ulcers Falls Urinary infections (in patients with catheters) VTE Why focus on these harms at the same time?

8. From the NHS Safety Thermometer pilot data we have identified that we could save half a million patients from these harms by focussing on harm free care… So what? …and measuring the 4 harms together

9. Pr Ulcer Risk Assessment Risk Management Nutrition & Hydration Medication Equipment Continence Falls CA-UTI VTE One plan – four harms

10. Imagine » No needless pressure ulcers » No needless harm from falls » No needless harm from catheters » No needless blood clots It’s not counting – it’s caring.....