serious incident annual report - nottingham north · data collected from 1.4.2015 to 31.3.2016 hp...
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Serious Incident Annual Report April 2015 – March 2016
Executive Summary This report provides an analysis of Serious Incidents (SIs) reported by Nottingham University Hospitals NHS Trust (NUH), Health Partnerships (HP), Circle Nottingham (CN), Nottingham West (NW), Nottingham North and East (NNE) and Rushcliffe (RCCG) Clinical Commissioning Groups (CCGs) and Independent Providers (GP practices) via the Department of Health Strategic Executive Information System (STEIS) during the period 1 April 2015 to 31 March 2016. It aims to provide assurance of a robust system of scrutiny, challenge and shared learning undertaken by the Quality and Patient Safety Team on behalf of Nottingham North East, Nottingham West and Rushcliffe CCGs and associate commissioners. There has been an overall decrease in the total number of SIs reported from the previous year in that 703 were reported across Nottinghamshire in 2015/16 compared to 1808 in 2014/15. Similarly, the numbers of SIs reported by providers where one of the the South Nottinghamshire CCGs is co-ordinating commissioner dropped to 207 in 2015/16 compared to 481 in 2014/15, 487 in 2013/14 and 514 in 2012/13. This decrease has in part been as a consequence of refreshed guidance on the national SI framework being issued in March 2015 which altered the threshold for SI reporting, re-defined the categories and ceased to grade SIs. As a consequence, whilst this report identifies SI activity against previous years it makes exact comparisons for some categories of SI unreliable. The main categories of SI reported in 2015/16 were pressure ulcers (PUs), Healthcare Associated Infections (HCAIs), falls, and maternity incidents. This is consistent with the reporting patterns in the previous year and compared to NHS England data for Nottinghamshire for 2015/16.
Pressure Ulcers
There has been a reduction in pressure ulcers from 280 in 2014/15 to 115 in 2015/16. It should be noted that previous years‟ figures included avoidable and unavoidable cases and from 2015/16 only avoidable cases required reporting. The number of avoidable cases has reduced from 135 in 2014/15 to 115 in 2015/16 which indicates an improving picture of reducing avoidable harm from pressure damage.
Falls There has been a significant reduction in falls that meet the SI criteria (resulting in moderate harm or above) from 75 in 2014/15 to 16 in 2015/16. The criteria for reporting falls SIs has not changed as a result of the revised guidance. The number of falls that do not meet SI criteria has also fallen in addition to the ratio of repeat fallers.
Healthcare Associated infections (HCAIs) HCAIs SIs have significantly reduced from 63 in 2014/15 to 39 for 2015/16. There has however been a slight increase in Methicillin Resistant Staphylococcus Aureus bloodstream (MRSAb) cases from 6 in 2014/15 to 7 in 2015/16.
Maternity There has been a significant reduction in maternity incidents from 39 in 2014/15 to 11 in 2015/16.
Never Events There were 6 Never Events reported by south CCG providers (5 NUH, 1 HP). This is a slight increase compared to 5 reported in 2014/15. There are however no similar cases compared to 2013/14.
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The Quality and Patient Safety Team continues to work with providers to ensure that incidents are reported and robustly investigated with appropriate action plans developed to prevent recurrence and enhance learning related to systems, processes and human factors.
Section Contents
Page
Introduction
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1 Putting patient safety first
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2 Serious Incident definition and reporting process
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3 Analysis of 2015/16 SI activity
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4 Serious Incident categories:
Pressure Ulcers
Slips, trips, falls
Healthcare acquired infections
Maternity
Never Events
Information Governance
10 17 21 23 25 & Appendix 1 26
5 Other Nottinghamshire providers: Sherwood Forest Hospital NHS Foundation Trust, East Midlands Ambulance Service and Nottinghamshire Healthcare NHS Foundation Trust
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6 Analysis of CCG monitoring of SIs
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7 Actions taken, quality visits, lessons learned, service improvements
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8 Reporting and sharing the learning
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9 Commissioner aims and objectives for 2016/17
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10 Conclusion
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11 Recommendation
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Introduction
This report provides an analysis of Serious Incidents (SIs) reported by Nottingham University Hospitals NHS Trust (NUH), Health Partnerships (HP), Circle Nottingham (CN), Nottingham West (NW), Nottingham North and East (NNE) and Rushcliffe (RCCG) Clinical Commissioning Groups (CCGs) and Independent Providers (GP practices) via the Department of Health Strategic Executive Information System (STEIS) during the period 1 April 2015 to 31 March 2016. It aims to provide assurance of a robust system of scrutiny, challenge and shared learning undertaken by the Quality and Patient Safety Team on behalf of Nottingham North East, Nottingham West and Rushcliffe CCGs and associate commissioners.
1. Putting patient safety first
Commissioning is a tool for ensuring high quality, cost–effective care. Quality is a key thread that underpins the work undertaken by commissioning groups. The mission is to improve the health and wellbeing of people in Nottinghamshire with a specific aim to improve quality by delivering improvements across the three domains of quality:
Patient Safety Patient Experience Clinical Effectiveness
Quality is only achieved when all three domains are met. To achieve a good quality service the values and behaviours of those working in the NHS need to remain focussed on patients first.
2. Serious Incident definition and reporting process
The NHS England Serious Incident Framework (March, 2015) describes Serious Incidents as ‘acts or omissions in care that result in; unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm - including those where the injury required treatment to prevent death or serious harm, abuse, Never Events, incidents that prevent (or threaten to prevent) an organisation’s ability to continue to deliver an acceptable quality of healthcare services and incidents that cause widespread public concern resulting in a loss of confidence in healthcare services’.
Never Events are „Serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers’.
Incidents are considered to be Never Events if:
The incident either resulted in severe harm or death or had the potential to cause severe harm or death.
There is evidence that the Never Event has occurred in the past and is a known source of risk (for example through reports to the National Reporting and Learning System or other serious incident reporting system).
• There are existing national guidance or safety recommendations, which if followed, would have prevented the incident from occurring.
• Occurrence of the Never Event can be easily identified, defined and measured on an ongoing basis.
In line with the Serious Incident Framework (March, 2015) all SIs must be reported onto the National Strategic Executive Information System (STEIS) within 2 working days with
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submission of final report to the Co-ordinating Commissioners 60 days from entry onto STEIS. SIs are no longer graded but there are three levels of investigation:
Concise (suited to less complex incidents which can be managed by individuals or a small group)
Comprehensive (complex issues which should be managed by a multidisciplinary team involving experts and/or specialist investigators)
Independent (for incidents where the integrity of the internal investigation is likely to be challenged or where it will be difficult for an organisation to conduct an objective investigation internally due to the size of the organisation, or the capacity/capability of the individuals or number of organisation/s).
Completed provider Root Cause Analysis (RCA) investigation reports are reviewed by the Quality and Patient Safety Team on behalf of Nottingham North East, Nottingham West and Rushcliffe CCGs. Closure on the national database is only approved once it is clear that there has been a robust investigation and the action plan appropriately addresses the root causes of the incident.
3. Analysis of 2015/16 Serious Incident activity Across Nottinghamshire 703 SIs were reported in 2015/16, of which 207 were attributable to NUH, HP, CN, South Nottingham CCGs and South CCG Independent Providers. In May 2015 the SI definition altered and in the case of pressure ulcers only „avoidable‟ incidents were reportable which partly explains the significant reduction of reported SIs compared to 2014/15. In addition CCGs had delegated responsibility from NHS England to report Primary Care acquired SIs on STEIS. It should be noted that the South Nottinghamshire CCG Quality Team also have responsibility for quality monitoring, including SI oversight, at BMI The Park Hospital and Ramsay Nottingham Woodthorpe Hospital, however neither of these providers reported any SIs in 2015/16.
Provider Concise
2015/16
Comprehensive
2015/16
Total
2015/16 2014/15 2013/14 2012/13
Nottingham University
Hospital (NUH)
82 24 106 239 232 286
Health Partnerships
(HP) (covering all
Nottinghamshire County
community services
including Residential
Care Homes - north and
south)
89 0 89 235 252 226
Circle Nottingham (TC) 0 3 3 5 1 0
South CCGs (NNE,
NW, Rushcliffe)
1 0 1 2 1 2
South CCGs
(Independent
commissioned provider)
8 0 8 0 1 0
Total 180 27 207 481 487 514
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The following tables provide the context of Nottinghamshire SI themes using NHS England data: NHS England (North Midlands) Serious Incident themes across Nottinghamshire, 2015-16 Please note that after 20 May 2015, categories were revised as a consequence of the new national guidance which was issued in March 2015 so data is presented according to pre and post 20 May.
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The following tables focus on SI themes for the South Nottinghamshire CCGs and the providers they are Co-ordinating Commissioner for:
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Themes by provider – 2015/16 (including those later removed*)
Six of the above SIs were classed as Never Events which are covered in more depth on page 25 of this report. *Incidents that have been removed from STEIS are mainly pressure ulcers that, following investigation, were found not to meet the SI criteria (i.e. were moisture lesions or stage 2 only).
Themes for year 2015/16 (including those later removed by
DoH)
Data collected from 1.4.2015 to
31.3.2016
HP NUH Circle Ramsay
Woodthorpe
BMI The
Park
South
CCG
South CCG
Independent
Contractor
(GP)
Total
Pressure Ulcer - stage 3 78 27 6 111
Pressure Ulcer - stage 4 4 4
HCAI/Infection control incident 2 36 1 39
Maternity services - intrauterine death 1 1
Maternity Services - maternal unplanned
admission to ITU
1 1
Maternity Services - unexpected admission
to NICU
2 2
Maternity services - unexpected neonatal
death
1 1
Maternity: obstetric: baby only 5 5
Maternity: obstetric: mother only 1 1
Slip, trip or fall 16 16
Screening issue 1 1 1 3
Confidential Information Leak 1 2 3
Diagnostic incident incl failure to act upon
test results
1 1
Infected Health Care Worker 1 1
Radiation incident 1 1
Surgical/invasive procedure 3 3
Commissioning incident 6 6
Blood product/transfusion incident 1 1
Medication incident 1 3 1 5
Abuse/alleged abuse of child patient by third
party
1
Medical equipment/devices/disposables 1
Incident since removed by DoH from STEIS 15 40 13 68
Grand Total 104 146 3 0 0 1 21 275
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SI numbers - reported by month - 2015/16
SI numbers – reported by quarter
SIs – reported by month/provider
2015-16 April May June July Aug Sept Oct Nov Dec Jan Feb March
NUH 12 10 12 12 6 4 3 9 4 12 15 7
HP 4 5 8 6 9 11 7 12 9 8 5 5
Circle 1 1 1
NNE Commissioned Service 1
NNE Primary Care 1 1 1 1
NW Primary Care 1
Rushcliffe Primary Care 1 1 1
18 15 21 19 15 15 11 22 14 22 22 13
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4. Serious Incident Categories The most frequently reported SI categories were:
Pressure Ulcers (stages 3 and 4 only are reportable on STEIS)
Falls with harm
HCAIs
Maternity
Never Events Pressure Ulcers (PUs) Staging is determined by the severity of the pressure damage. Stages 1 and 2 do not meet SI criteria and are not reportable on STEIS. Stages 3 and 4 indicate deeper more invasive tissue damage and consequently more severe. Patients with a stage 4 wound have a higher risk of developing a life-threatening infection due to their depth.
NHS England (North Midlands) data shows that PUs were the highest category of SI reeported with 265 PUs reported in Nottinghamshire during 2015-16. PUs were also the highest category of SIs reported by the south CCG providers with 115 reported in 2015/16, which had reduced from 280 in 2014/15. This is explained in part by the alteration in reporting criteria which removed unavoidable PUs from being classified as an SI as a consequence of the new national framework guidance. When comparing avoidable damage a reduction is evident in PU damage as there were 115 in 2015/16 compared to 135 in 2014/15 indicating that there has been a reduction in real terms not just as a result of revised reporting thresholds. To validate the new criteria NUH and HP have agreed to external scrutiny of a randomly selected number of unavoidable PUs to ensure robust classification in line with the national framework.
Total PUs
2015/16 (avoidable only)
2014/15 (avoidable and unavoidable)
2013/14 (avoidable and unavoidable)
2012/13 (avoidable and unavoidable)
115 (82 HP, 27 NUH, 6 Primary Care)
280 (230 HP, 50 NUH)
352 (247 HP, 104 NUH, 1 NW CCG)
297 (179 HP, 118 NUH)
PUs - by provider 2015/16 (stages 3 & 4 combined)
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Pressure Ulcers by Quarter:
16
22
26
14
8 9
4 6
2 0
2 2 0
5
10
15
20
25
30
Q1 Q2 Q3 Q4
Stage 3 PUs - by Quarter (2015/16)
HP stage 3
NUH stage 3
Independent provider- stage 3
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Total Stage 3 PU numbers:
2015/16 2014/15 2013/14 2012/13
111 = 27 NUH, 78 HP, 6 Primary Care acquired
259 = 50 NUH, 209 HP
334 = 103 NUH, 230 HP, 1 NW CCG
297 = 118 NUH, 179 HP
Avoidable cases:
It is evident that generally there has been a reduction in avoidable stage 3 PUs from the previous year. Total Stage 4 PU numbers:
2015/16 2014/15 2013/14 2012/13
4 = 4 HP, 0 NUH 21 = 21 HP, 0 NUH
18 = 17 HP, 1 NUH 24 = 24 HP, 0 NUH
Avoidable cases:
Within HP there was an increase from 2 to 4 stage 4 avoidable PUs from the previous year. NUH have had no stage 4 incidents since 2013/14. Key work during 2015/16 by providers to enhance PU prevention and PU care delivery is outlined below: NUH Key RCA themes: (Information is taken from the NUH Annual Pressure Ulcer report 2015/16)
NUH has been working to achieve the internal target set in 2014 by the PUOG (Pressure Ulcer Operational Group) to reduce avoidable pressure ulcers by 50% over a 3 year period. NUH wanted to be in line with the NHS England initiatives „Sign up to Safety‟ and „Saving 6000 Lives‟ by reducing avoidable harm events by 50% over a three year period. NUH is now entering the final year of that ambition.
HP NUH Primary Care
2015/16 2014/15 2015/16 2014/15 2015/16 2014/15
Stage 3 78 103 27 30 6 Not previously recorded
HP NUH Primary Care
2015/16 2014/15 2015/16 2014/15 2015/16 2014/15
Stage 4 4 2 0 0 0 Not previously recorded
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Overall NUH Target reduction: Avoidable Pressure Ulcers –
Occupied bed days
Baseline Actual Target Actual Target Target
Stage 2013/14 2014/15 2014/15 2015/16 2015/16 2016/17
Stage 2
0.65
0.57
0.54
Avoidable
0.47*
0.41
Avoidable
0.33
Avoidable
Stage 3
0.13
0.05
0.10
Avoidable
0.04
0.08
Avoidable
0.06
Avoidable
Stage 4
0.00
0.00
0
Avoidable
0.00
0
Avoidable
0
Avoidable
Last year (2014/15) the NUH Tissue Viability (TV) team planned to focus on the following key areas which had been identified during the RCA process as requiring updating or further review - Management of Moisture Lesions Ineffective repositioning Poor management of non-concordance Lack of patient involvement in the RCA process Inaccurate reporting / duplicate reporting Actions taken: A new PODCAST for Moisture lesion management Training sessions for Health Care Assistants for effective repositioning Guidelines / recommendations for the management of non-concordance A patient interview now forms part of the RCA investigation-not just the duty of
candour process Monthly review of all Pressure Ulcer Datix Incidents by the TV Team to remove
duplicates and ensure accurate reporting – However encouraging the wards to investigate these timely remains challenging, patients are often transferred out of the reporting area before these can be completed.
Local Improvement Work – stretching days between events (avoidable & unavoidable pressure ulcers) Local project work continues and the four wards targeted during 2015/16 have all performed well. The plan was to continue rolling this out (4 wards every 4 months) but with increasing clinical demands NUH were unable to realise this ambition. The current wards have also required support for a longer period of time than had been anticipated.
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As part of the action following a Stage 3 pressure ulcer a „patient safety walk around‟ with a member of the TV team is undertaken to review current ward practices; this gives the clinicians and TV experts an opportunity to add any additional recommendations to the action plan.
Ward Pressure ulcer Stage
Baseline Average days between events 2014/15
Speciality Trajectory
2015/16
Target
Performance Current PDSA Update
Gervis Pearson
2
17
42%
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27 - by Q3
Moisture Lesion
Management
Completed Dec 2015
C52
2
34
21%
33
50 - by Q3
Effective
repositioning
Project
Complete
AICU
2
4
40%
7
6.5
Nutrition / NG
tubes
Ongoing
F21
2
17
50%
30
29
Ward routine & repositioning
regimes
Project
Complete
Ward Pressure ulcer Stage
Baseline Average days between events 2014/15
Speciality Trajectory
2015/16
Target
Stretch Target
Performance Current PDSA Update
D58
2
16
21%
20
41
42
Incomplete due to ward closure
E14
2
35
50%
61
N/A
46
TBD
Ongoing
NUH feel that there is little „new„ learning from the RCA process, and the greatest improvements have been achieved by working directly with ward teams identifying small changes to practice that realise the improvements required.
NUH have identified the next 4 wards that are the next highest reporting areas of PU damage that they plan to work closely with as:
Berman 2 CCD Hogarth Edward 2
Thematic reviews and „patient walk rounds‟ will be undertaken to establish a baseline assessment and this information will then be used to identify any key areas for improvement, supported by structured support and education to the ward teams, assisting them to develop PDSA cycles and measure their improvement.
An additional area of work during Q1 of 16/17 has been to explore inherited PU damage as part of the Emergency Department pathway to strengthen assurances of quality and safety relating to missed performance targets. This includes enhanced support from the TV team to review care pathways of inherited damage and support staff around the following:
Timely risk assessments
Improve skin assessments and frequency - „react to red‟
Improved use of SSKIN bundle
Expedite the time patients are transferred off trolleys and onto bed – logistical problem with a lack of space and availability.
Shortage of pillows for effective repositioning
No heel „off-loading‟ devices
Improved use of SSKIN bundle & frequent repositioning ( which can safely be performed on a trolley )
Trolley mattress inspections for „integrity‟ testing rebound
Review new trolleys on the market
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HP Key RCA pressure ulcer themes: (Data provided by Amy Barksby, Audit Facilitator, HP and the NHCT 2015/16 Quality Report)
Trends analysis by locality Mansfield and Ashfield Newark and Sherwood Nottingham North & East
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Nottingham West Rushcliffe
HP initiatives: The NHCT Trust Quality Report 2015/16 identified 6 safety priority workstreams for the Sign Up to Safety campaign, one of which was PUs. A TV Group oversees the implementation of the quality and safety improvement plan and monitors progresses outlining key achievements and any issues. The plan has achieved 12 out of 14 improvement actions. There are 2 improvement actions regarding self-care that are being finalised. Eliminating stage 3 and stage 4 acquired avoidable Pressure Ulcers remains challenging. Improvements in training and educational programmes should help to delivery better care going forward.
2016/17 priorities are to reduce avoidable harm with focus on pressure ulcers. The ambition is to have no incidents causing severe harm or death. The numbers of stage 3 and 4 pressure ulcers and number of repeated issues identified through Root Cause Analysis that could have prevented pressure ulcers will be monitored.
PU incident origin The majority of PUs reported originated in the patient‟s own home and this has decreased from 57% in 2014/15 to 45% in 2015/16. The Hospital/Hospice category shows an increase from 18% in 2014/15 to 24% in 2015/16 and the Care Home sector shows no change from 2014/15. Of the four stage 4 PUs, 3 originated in the patient‟s own home and 1 in a care home (residential).
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46%
22%
32%
Origin of PU incident 2013/14
Patients OwnHome
Care Home
Hospital/Hospice)
Slips/Trips/Falls with harm NHS England (North Midlands) data shows that 41 Slips/Trips/Falls were reported in Nottinghamshire during 2015/16. South CCG providers - Slips/trips/falls
2015/16 2014/15 2013/14 2012/13
NUH 16 NUH 75, HP 0, Circle 0 NUH 51, HP 0 NUH 49, HP 0
16 Slips/trips/falls SIs were reported in 2015/16 - all attributable to NUH and a significant decrease on 2014/15 and decreasing trends during 2015/16, none of which were attributed to deaths from an inpatient fall. HP has reported no fall SIs since April 2012 and Lings Bar Hospital has a robust patient assessment and monitoring system from admission.
25%
18% 57%
Origin of PU incident 2014/15
Care Home
Hospital/Hospice
Patient's OwnHome
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Main categories of injury caused by falls at NUH, 2015-16
2015/16 2014/15 2013/14
2 3 Death related falls
2 18 2 Neck of femur/femur related
1 1 Fractured Fibula
1 Fractured tubercle
2 1 Fractured distal radius
1 1 1 Fractured elbow
3 21 10 Fractured hip
1 2 Fractured humerus
3 3 Fractured shoulder
1 1 Fractured thumb/hand
1 Fractured knee
2 Fractured ankle
1 2 Fracture to Pubic ramus/pelvis
1 3 Fractured ribs
8 16 7 Skull//face/head bleed related
2 4 Fractured wrist
1 Big toe injury
2 Periprosthetic fracture
1 1 Fracture of T11 T12 of spine/lumbar fracture
NUH Falls (Data provided by NUH).
NUH contributed to the first National Audit of Falls in Hospitals in March and April 2015. The national average rate of inpatient falls was found to be 6.63per 1000 Occupied Bed Days (OBDs). The NUH rate (for 14/15) was 4.42 per OBDs which was a third lower than the national average. Whilst NUH have reduced their one off falls and falls with harm the main challenge is around patients who experience repeated falls.
Inpatient fall rates – April 2010 - December 2015
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Falls associated with harm – per 1000 bed days (April 2010 – April 2016)
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Repeat fallers – ratio of falls to fallers April 2010- April 2016
NUH targets for 2016/17:
Key themes from falls within NUH
Lack of toileting regime
Lack of supervision/observations
Lack of lying and standing BP being recorded Initiatives: The Trust implemented the Nursing Red Flag alerts recommended by NICE across all acute adult inpatient ward areas. This supported staff to identify when patient safety may be compromised and additional staffing required. Wards needing to cohort patients at risk of falls or patients needing 1:1 supervision due to confusion and at risk of falls have
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been highlighted by the Nursing Red Flag alert alerting to the need for additional staff to support to cohort and prevent falls. NUH have identified the following additional actions:
NUH will commission and scrutinise Root Cause Analysis (RCA) in all cases of repeat falls and refine the Falls Prevention Algorithm and the associated Falls Prevention Care Checklists
The RCA template has been shortened with more emphasis on key themes
The Inpatient Falls Committee will meet only twice monthly (previously three). The time released by a shorter RCA process will permit the development of „Assurance Assessment Visits‟ as NUH have found these supportive interventions have worked well to reduce the harm accruing from pressure ulcers so wish to use this approach to benefit falls reduction. NUH feel that this approach will enhance falls prevention by providing advice and guidance through direct observation of care and the ward environment.
The RCA threshold for head injuries will be refined to encompass only those events associated with evidence of significant brain injury (fall in GCS and need to CT brain scan)
NUH report that „previous strategies to reduce falls and associated harm focused on raising general awareness, provision of training, supportive guidance, and development of ward-based Falls Champions and the Falls Prevention Team. This facilitated our more consistent provision of specific interventions in clinical areas where large numbers of our patients were at high risk of falling. Our continuing strategy remains based upon:
1. Effective management of delirium 2. Delivery of effective 1:1 or cohort nursing for patients at highest risk of fall 3. Proactive instigation of toileting regimens where appropriate 4. Reducing repeat falls 5. More frequent and correct use of ultra-low beds 6. Effective delivery of RCA action plans at the clinical front line 7. Better knowledge management – database allowing cross-reference between
characteristics of fall events and actions implemented 8. Integration with other safety themes including infection control and pressure ulcer
management’
Healthcare Acquired Infections (HCAIs) NUH HCAI SIs are scrutinised and closed on STEIS on behalf of the three south CCGs by Elaine Belshaw, Quality Manager, Infection Control. Countywide community HCAIs are scrutinised and closed on STEIS by Sally Bird, Head of Service, Community Infection Prevention and Control (IPC) Team, hosted by Mansfield and Ashfield CCG on behalf of the five Nottinghamshire CCGs. A separate IPC Annual Report 2015/16 is available and has been submitted to the CCG Governing Bodies. NHS England (North Midlands) data shows that 48 HCAI SIs were reported in Nottinghamshire during 2015/16. For south CCG providers there was a significant reduction in HCAI cases; from 69 down to 39. South CCG provider - HCAI related SIs reported All cases of MRSAb are reported as SIs. C Diff cases are only reported if the patient suffers moderate or above harm and lapses in care can be demonstrated following post infection review.
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2015/16 2014/15 2013/14 2012/13
39 (HP 2, NUH 37) 69 (HP 4, NUH 63, NW 1, NNE 1 35 58
HCAI SIs - by type and provider 2015/16 Note: Community MRSAb and CDiff cases are now registered against the patient’s CCG and not HP in terms of numbers. However, following a Post-Infection Review, the outcome can result in the re-assignment to another organisation (*).
Category HP NUH RCCG NW NNE Circle
Clostridium Difficile (C Diff) 1* 3
MRSA 6 1
Hepatitis B 1
Influenza A 2
Norovirus 1 (John
Eastwood Hospice)
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Pneumocystis Pneumonia (PCP) 1
Rotavirus 1
Diarrhoea & Vomiting (D&V) 8 NUH data provided by Elaine Belshaw, Quality Governance Manager, Infection Prevention and Control, NHS Nottingham City CCG) Clostridium Difficile (C Diff) NUH: The CCG is currently working with NUH to enhance local C Diff toxin positive assessment processes to aid onward assurances around learning. Whilst NUH were over trajectory by 4 cases for 2015/16 when viewed against their comparator organisations their rate of C diff infections per 100,000 bed days was the second lowest. Methicillin Resistant Staphylococcus Aureus (MRSA)
NUH: The NUH MRSA Objective (2015-16) was zero tolerance. There were six cases assigned to the Trust.
3 cases were clinically unavoidable
1 case was clinically avoidable
2 cases were contaminated sample / colonised line and not actual infections
The Trust has evidenced consistent high levels of compliance with MRSA screening since 2011 and their policy is more comprehensive when compared to the latest national guidance which has ensured positive cases were less likely to be missed. There had been a downward trend in numbers of MRSA from clinical samples up to February 2016. Trust acquired MRSA Blood Stream Infections have been reported in single figures for the last 5 years. MRSA reduction remained a priority for NUH and the Nottinghamshire health economy. Actions focused on:-
Enhancing compliance with effective antimicrobial stewardship
Strengthening and sustaining compliance with screening and decolonisation, hand hygiene, equipment and environmental cleanliness and decontamination
Improving infection control communication and information sharing across the health economy
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NHS Rushcliffe CCG NHS Rushcliffe CCG reported 1 MRSA case against a target of zero. This was a community acquired case of MRSA Panton-Valentine leucocidin (PVL) bacteraemia and was found to be linked to an outbreak in a residential care home involving 2 cases. HCAI numbers - by month The rise in HCAI SIs in quarter 4 at NUH is consistent with the increasing prevalence of infectious outbreaks at that time of year e.g. Influenza, Diarrhoea & Vomiting and Norovirus.
The CCG and NUH have agreed that outbreaks will now be clustered together into one RCA investigation where there are several patients involved to enable better focus on key themes and learning around systems, environments and human factors. Environmental cleanliness has been a key focus for NUH in Q.3 and Q.4 and four joint Infection Prevention and control (IPC) focused quality visits were undertaken at QMC between June – December 2015 by the CCG and the Trust Development Authority (TDA). These were a mixture of unannounced and announced visits to a range of clinical areas and it was clear that NUH had implemented a significant amount of proactive initiatives to address previous significant concerns relating to cleanliness and basic IPC measures. Assurances were gained at these visits of:
Strategic leadership and Board ownership of IPC environmental concerns.
Engagement of staff at all levels in IPC environmental cleanliness.
Effective sub-contracting arrangement with cleaning and housekeeping provider
Clean environments.
A repeat unannounced visit in March 2016 to the City Campus identified that there were sustained improvement for the rest of 2015/16 and there were repeat visits to monitor this planned for 2016/17. Maternity related incidents (NUH) Post 20 May 2015, STEIS SI categories altered resulting in just 3 maternity categories (baby only; mother and baby; mother only) being applicable, although the categories of unexpected admission to NICU, unexpected neonatal death, intrauterine and unplanned admission to ITU were in use on STEIS from 1 April – 19 May 2015 and are therefore included in this report. NUH agreed with the lead commissioner that they would only
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report incidents as SIs where there was harm or learning in relation to these categories following the change in the national SI framework.
NHS England (North Midlands) data shows that 22 maternity SIs were reported in Nottinghamshire during 2015/16. 11 maternity serious incidents were reported by NUH for 2015/16 which was a significant reduction from 2014/15. Given the reduction in SIs reported in 2015/16, it has been agreed with NUH that a random sample of non-SI incidents will be reviewed during 2016 by a panel of CCG staff to ensure robust decision making around determination of SIs.
2015/16 2014/15 2013/14 2012/13
11 39 38 32
Maternity SIs 2015/16 (by month)
Maternity SIs by individual category
At NUH, the Maternity Governance Team (MGT) has continued to maintain the focus on the importance of robust governance processes including active risk management. Incident reporting continues to be promoted across the maternity service; and training has continued to be provided across the maternity and obstetric teams to support this via
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a selection of events. Events have included multi-professional divisional days and induction training for new doctors and midwives. The Maternity Dashboard tool is used to provide a tabular representation of a variety of incident, performance and service delivery indicators. It is RAG rated (red, amber, green) and the parameters set, where possible, against nationally derived standards. The dashboard is reviewed at the Specialty Clinical Governance Meeting each month; red ratings are discussed and if there is a trend to red rating, actions are devised and overseen.
NUH Summary of Learning from Maternity Incidents 2015/16 (data provided by NUH)
One of the 11 incidents was classed as a Never Event – retained vaginal swab. The Serious Incident report from this case has identified learning for the Maternity services which will contribute towards safer delivery of care. The guideline for “Maternity swabs, Instruments and Sharps counting is to be reviewed to bring it into line with NUH‟s “Theatre Swabs, Instruments and Sharps Checking Policy. The Intrapartum Booklet is to be redesigned to ensure the swab counting documentation is in the most relevant place. Once these changes are implemented all professionals involved in Swab counting will be informed and a training programme will commence. The type of swab that was involved in this case has already been removed from Labour ward areas. An Audit is planned to review compliance of safe swab counting procedure.
Never Events Nationally there were 345 Never Events reported in 2015/16 – an increase compared to 308 cases in 2014/15. At the time of this report it should be noted that these are provisional figures only and subject to change once sufficient time has elapsed for local incident investigation and national analysis of data to take place. National Never Events 2015/16 (provisional)
Wrong site surgery 137
Retained foreign object post procedure 83
Misplaced naso or oro gastric tube 39
Wrong implant/prosthesis 40
Wrong route administration of medication 23
Overdose of insulin due to abbreviations or incorrect device 8
Most Frequently Reported Incidents PPH
3rd or 4th DegreeTearsCommunicationFailureStaffing
Documentation andHealth Records
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Overdose of methotrexate for non-cancer treatment 2
Mis-selection of high strength midazolam during conscious sedation 1
Transfusion or transplantation of ABO incompatible blood components or organs 5
Failure to install collapsible shower or curtain rails 2
Mis-selection of a strong potassium containing solution 1
Falls from poorly restricted windows 4
South CCG Provider Never Events 6 Never Events were reported by south CCG providers (5 NUH, 1 HP). This is a slight increase to 5 reported in 2014/15.
STEIS REF PROVIDER: Date reported THEME
2015/29661 NUH 11/09/2015 Wrong route administration of medication - (intravenous connection and administration of an epidural infusion)
2015/35517 NUH 11/11/2015 Wrong route administration of medication - (wrong administration of oral morphine sulphate)
2015/35887 NUH 17/11/2015 Wrong implant/prosthesis – (wrong implant). „Compact‟ chin plate was inserted and secured with screws from
the intended „Matrix‟ system).
2015/39179 NUH 22/12/2015 Retained foreign object post-procedure – (inadvertently retained vaginal swab following childbirth)
2016/3873 NUH 10/2/2016 Wrong route administration of medication – (Wrong route administration of oral Haloperidol intravenously)
2016/7337 HP 15/3/2016 Misplaced naso-gastric tube (child)
Conclusions and recommendations from the NUH Never Event Root Cause Analysis Reports can be found in Appendix 1. The HP investigation for 2016/7337 is still being undertaken with the Safeguarding Team. Information Governance (IG) Three IG SIs were reported by south CCG providers in 2015/16 - an increase of 1 from 2014/15.
2015/16 2014/15 2013/14 2012/13
3 2 (HP and Circle Nottingham) 0 2 (NUH)
Two IG SIs were reported by Circle Nottingham. The first involved patient data contained in a Microsoft Excel spread-sheet being sent to the intended recipients via a non-encrypted email. The incident was investigated and actions were put in place to minimise the risk of future breaches and to ensure learning and improvement. The investigation report was scrutinised by the CCG quality team and an update on implementation of actions reviewed at the April 2016 Quality Scrutiny Panel. The second incident involved patient information being sent to an external provider via email.
Following the second breach, an extra-ordinary Information Security Forum meeting was held to review the incidents. An immediate review of the Information Governance and
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Security training was undertaken to ensure that this was appropriate. Amendments were made in response to the incident. A number of additional sessions were scheduled and attended by appropriate staff. Learning from patient safety incidents is shared at Circle Nottingham‟s Clinical Governance and Risk Management (CGRM) committee which is attended by representatives from each service / gateway within the organisation and a member of the CCG‟s quality team. The third IG SI was reported by HP. City CCG had requested „numbers only‟ of all patients who had accessed Lings Bar Hospital for a specified period. This request was forwarded to a data analyst who responded with a summary which contained patient identifiable information for the 964 patients concerned. Actions taken were:
Individuals in Applied Information Team must take responsibility for checking all requests (not just external requests) thoroughly to ensure only relevant data requested is prepared and sent
Individuals in Planning and Performance Team to check each request and the data that has been supplied from the Applied Information Team, before sending it on to the requester, either internal or external to the Organisation.
Both team managers to review the checking and validation processes within their department to ensure that rigorous „checking and signing off‟ of information is written into these processes. Both team managers to ensure the team are all aware of the revised process and reinforce the importance of this taking place before sending out every request related to patient related information.
Passwords must not be sent via email. Either requester rings for the password or the sender rings with the password.
The Applied Information Team to cease using a generic password for all information requests. A unique password to be used for each information request.
5. Other Nottinghamshire Providers: SFHFT, EMAS and NHCT
Although not the lead commissioner, the Quality and Patient Safety Team, on behalf of the south Nottinghamshire CCGs, has monthly oversight of numbers and themes for Sherwood Forest Hospital Foundation Trust (SFHFT), East Midlands Ambulance Service (EMAS) and Nottingham Health Care Trust (NHCT). Note: Graphs show all pre and post 20th May changes to categories.
2015/16 2014/15 2013/14
SFHFT 59 97 103
EMAS 58 47 39
Notts Healthcare Trust 93 126 133
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SFHFT 2015/16 by theme: Never Events: 1 x Surgical/invasive procedure (wrong site surgery). Removal of wrong non-malignant mole from scalp. Category „other‟: Failure to Monitor. OPD Appointment delay – subsequent detached retina.
NHCT 2015/16 by theme: Never Events: None.
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EMAS 2015/16 by theme: Never Events: None.
6. Analysis of CCG monitoring of Serious Incidents
The SI Framework sets a 60 day timescale for providers to submit Root Cause Analysis reports (RCAs). Where providers are unable to meet this deadline, an extension request must be submitted prior to the due date for approval by the Deputy Director of Nursing and Quality. Extensions are permitted up to a maximum of 20 working days. 207 RCAs were received from providers. 40 (19.32%) of the RCAs were Healthcare Acquired Infections and were reviewed separately by the IPC team and are therefore marked as outwith. RCA reports received within the 60 day agreed timescale – 2015/16 Total RCAs:
30
5%
1%
94%
HP
Late
Outwith
On time
By provider:
Breakdown of extensions requests:
HP NUH Circle
Late: 4 8 2
With no extension requested 0 1 2
With extension requested (and approved by CCG) 4 7 0
Of the 3 RCAs that were late with no extension requested, the number of days over timescale was: NUH (6 days), Circle (2 days), Circle (2 days) Extension reasons:
3 Further clarity sought from speciality/consultant
1 RCA had to be discussed at Encephalopathy meeting before submission to CCG
3 Needed to locate staff members who had left organisation or were on leave
1 Miscommunication resulting in missed deadline
1 Chairperson replaced due to conflict of interest
1 Extra time needed to convene extra panel
1 Delay as RCA awaiting Governance approval to submit
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7. Actions taken, quality visits, lessons learned, service improvements
Monitoring of wards and care homes The Quality and Patient Safety team log all wards and care homes relating to Pressure Ulcer incidents to highlight any hotspots and to take appropriate action. Care home concerns are shared with Nottinghamshire Adult Safeguarding Leads and the Local Authority. Whilst Quality monitoring visits are undertaken routinely they are also initiated as a result of issues highlighted in RCAs or due to prevalence in any one location. Quality visits Seven quality visits took place during 2015/16 as a direct response to Root Cause Analysis findings from HP and NUH.
HEALTH PARTNERSHIPS
Date Area Reason for Visit Outcome
18.05.15 JAKS federation
Assure on action being taken to address workforce and capacity issues which had led to avoidable pressure damage on 6 occasions.
Now enhanced clinical and managerial leadership in the locality since March 2015. Clinicians being developed to undertake DN role with support, supervision and guidance. Developing highlight summaries/dashboards to identify any areas of concern which may impact on quality and safety
03.07.15 NNE team Seek assurance on action being taken on staffing issues/PUs
NNE Senior management team reviewing PU management by staff and senior nurses, which includes allocation of visits, caseload management, lack of senior staff to provide leadership. Action plan devised to address issues and follow up visit undertaken to meet with clinical staff.
NUH
Date Area Reason for Visit Outcome 12/08/2015 1. Corridors
and stairwells
2. E12 3. C31 4. C25
Planned visit by TDA and CCG
Follow up to assess progress
“As already stated we acknowledge the amount of work already undertaken but remained disappointed to observe key issues such as “clean” bed spaces which were dirty, mattress ingress, dirty pull cords at QMC”.
In response:- Trust to provide the reviewed delivery plan approved by the Executive Board within 10 working days. These issues will be followed
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up at the TDA IDM and the CQRM
Revisit by TDA and CCG in approximately ten weeks in order to provide time for actions to be addressed (proposed 21st October 2015).
21/10/2015 1. E12 2. F18 3. D58
Planned visit by TDA and CCG
Follow up to assess progress
Progress in the clinical area was mixed. Trust appeared fully engaged with the improvement process from Board to ward and that this is part of on-going progress It remained disappointing to still identify breaches in cleanliness and basic IPC on two out of the three wards visited: D58, E12 and F18. The Trust not compliant with Criterion 2.1; Code of Practice on the prevention and control of infections and related guidance (DH, 2010). In response:- Trust to provide the reviewed delivery plan approved by the Executive Board within 10 working days. Issues will be followed up at the TDA IDM and the CQRM.
Matrons IPC Masterclasses delivered by TDA 17/11/2015
Planned revisit to assess progress against plan on 2nd December 2015Revisit by TDA and CCG in approximately ten weeks in order to provide time for actions to be addressed (proposed January 2016).
02/12/2015 1. C54 2. C53 3. C52 4. D57
Planned visit by TDA and CCG
Follow up to assess progress
TDA/CCG assured that: The strategic leadership of IPC was strong and that the Board were fully engaged. IPC is owned at all levels. The environment was clean. In response:-
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The Trust has been de-escalated to TDA IPC escalation Level 3.
16/03/2016 1. Lister 2 2. Fleming
Ward
Unannounced quality visit by CCG
Follow up to assess progress and sustainability
Summary of visit: “It was clear that the learning from the previous NHS Trust Development Authority and CCG visits had been disseminated and actioned. Staff were aware of the infection prevention and control challenges in their clinical areas and it was enlightening to hear the plans in place”.
GP practices 8 SIs were attributable to GP practices; 6 Pressure Ulcers, 1 Screening Issue and 1 MRSA. Learning and actions taken: Pressure ulcers:
Practice would discuss patients on admission avoidance and palliative registers to think about PU prevention. All new diagnosis cancer care reviews to assess risk of PUs. All GPs to be aware of need to carry out full assessment for PUs when undertaking home visits/or reviewing at risk patients.
To identify patients who are at risk of pressure ulcers (score of over 10 on pressure ulcer risk assessment tool), format a register and monitor as a team
Practice to issue a reminder to use PU risk assessment tools proactively
To use PU risk assessment tool and scoring system. To ask patients/carers about pressure areas for those at risk. Will educate family carers about the signs and early features of PUs.
Screening issue (missed Pertussis vaccination):
The practice put a robust recall system in place with better communication links with the Community Midwives and a plan to enable shared records for access by Community Midwife Teams.
MRSA:
Learning was linked to the Care Home involved. Action plan around staff completion or refresher of infection control procedures and amendment of staff check lists to ensure more detailed recordings logged.
8. Reporting and sharing the learning
National Reporting and Learning System data highlights:
‘The comparative reporting rate summary provides an overview of incidents reported by NHS organisations to the National Reporting and Learning System (NRLS) occurring between 1 April 2015 and 30 September 2015. NUH reported 10,066 incidents (rate of 39.85) during this period’. NUH are in the middle 50% of reporters.
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Organisational Safety Report 1/4/2015 – 30/09/2015 (NRLS) Comparative reporting rate, per 1000 bed days, for 136 Acute (non specialist) organisations. The median reporting rate for this cluster is 38.25 incidents per 1,000 bed days.
Sharing the learning The three south CCGs continue to strive for a reduction in patient harm through the sharing of key learning and recommendations with associate commissioners and other NHS organisations via:
Quality Scrutiny Groups for HP/NUH/Circle/Nottingham Woodthorpe and BMI The
Park hospitals
Quality Surveillance Group/NHS England (North Midlands)
NHS England Serious Incident Network
Quality visit reports
Quality dashboards
Quality and Risk Committee
Commissioning for Quality and Innovation (CQUIN) review meetings
Nottinghamshire-wide HCAI group
Quality monitoring visits/information sharing with Nottinghamshire Adult
Safeguarding Leads/ South CCG Care Home Subgroup
Nottinghamshire Nursing Cabinet The Quality and Patient Safety „Quality Counts‟ Newsletter
The South CCG Quality report
Primary Care Quality meetings
Provider Focus reports
Primary Care Quality Groups in each South Nottinghamshire CCG
Protected Learning Time Events
NUH
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9. Commissioner aims and objectives for 2016/17
Sustain and continue to develop measures for primary care around quality assurance
Support sharing of learning by working with Patient Safety Collaborative and associate commissioners
Support providers to expand Root Cause Analysis investigations to better capture human factors
10. Conclusion Robust incident reporting and investigation processes allied with an open, honest and mature learning culture remain an important component of delivering safe health care and improving outcomes. Commissioners play a vital role in ensuring that organisations have these processes in place and that learning as a result of adverse incidents is identified and embedded in practice. The Quality and Patient Safety Team will continue to work with providers to support continual improvement through the analysis of themes and trends and sharing of learning and best practice.
11. Recommendation The Quality and Risk Committee is asked to review and take assurance from the Serious Incident Annual Report. Liz Gundel Quality Support Officer Becky Stone Assistant Director of Quality and Patient Safety Quality and Patient Safety Team - NNE, NW and Rushcliffe CCGs October 2016