Next Generation

Medication Safety

Medicines remain the most common therapeutic intervention and biggest cost to the NHS at £13.8bn – only secondary to staffing. Data from the National Reporting and Learning System (NRLS) 2005-2010 show that medication incident reports were the second highest number of all incident reports at 526,186, this equates to 9.68% of total.  Of these 822 involved severe harm or death of a patient.

There is a growing community of people who want to better understand the scale of the issue of medication error and who want to work together to reduce the number of patients harmed from medication errors. We have started by collecting real time data at the point of care.

As a measurement tool for improvement, The Medication Safety Thermometer focuses on Medication Reconciliation, Allergy Status, Medication Omission, and Identifying harm from high risk medicines in line with Domain 5 of the NHS Outcomes Framework.

The next generation in useThe tool has been developed by a community of testers who have iteratively tested the tool to ensure it is quick and easy to use and gives useful information which can be used for local improvement.  

As a point of care survey The Medication Safety Thermometer follows a three step process in order to identify harm occurring from medication error.  Data are collected on one day each month and enable wards, teams and organisations to understand the burden of medication error and harm, to measure improvement over time and to connect frontline teams to the issues of medication error and harm, enabling immediate improvements to patient care. Data can be used as a baseline to direct improvement efforts and then to measure improvement over time.

Data are collected across the health economy in acute hospitals, community hospitals, intermediate care, care homes and district nursing services (for district nursing only where nurses administer medicines).

The NHS Safety Thermometer web tool will allow you to submit and analyse your data through a suite of resources. Go to the Safety Thermometer website to download the testing pack and test on patients today!

Mental Health

The NHS Mental Health Safety Thermometer allows teams to measure harm and the proportion of patients that are ‘harm free’ from self-harm, violence and aggression, restraint, physiological safety and omissions of medication.  This point of care survey is used to collect data on patients who access mental health services in both acute and non-acute settings with a recommend sample of 100% of appropriate patients on one day each month. 

The Mental Health Safety Thermometer was tested and developed throughout 2013/14 and is now available nationally for organisations to use to measure improvement over time and collect meaningful data on these commonly occurring harms.

The NHS Safety Thermometer web tool will allow you to submit and analyse your data through a suite of resources. Go to the Safety Thermometer website to download the testing pack and test on patients today!

Maternity

Having a baby in the UK is the safest it has ever been. However human factors, working culture, communication and teamwork are key themes associated with avoidable harm in maternity care.

The NHS Maternity Safety Thermometer allows maternity teams to take a temperature check on harm and records the proportion of mothers who have experienced harm free care, but also records the number of harm(s) associated with maternity care. The Maternity Safety Thermometer measures harm from Perineal and/or Abdominal Trauma, Post-Partum Haemorrhage, Infection, mother baby separation and Womens perception of Safety.  In addition we are identifying those babies with an Apgar of less than Seven at Five Minutes and/or those who are admitted to a Neonatal Unit.

This is a point of care survey that will be carried out on one day per month in each maternity service on all postnatal mothers and babies. Data is collected from postnatal wards, women’s homes and community postnatal clinics.

From November 2014 the Maternity Safety Thermometer is available nationally for organisations to begin collection data and analyse locally through the on-line suite of analysis tools available.

Go to the Safety Thermometer website to download the testing pack and test on patients today!

Children and Young People

An exciting new development is underway to create specific Safety Thermometer to measure commonly occurring harm within Children and Young Peoples services. We are working organisations including Birmingham Children’s Hospital NHS Foundation Trust and Great Ormond Street Hospital to develop and test the tool adhering to the key Safety Thermometer design principles and methodology.

This measure is currently being tested include Pediatric Early Warning Score (PEWS), Extravasion, Pain and Skin Integrity with further work being carried out around Medication Safety. A monthly testing group call is held to allow new organisations an opportunity to engage in the development and support in data collection throughout the pilot.

If you are interested in getting involved in the testing or would like to know more about how your organisations can use this tool please contact us on: admin@harmfreecare.org