VTE Showcase Maintaining the Momentum. Mike Durkin Director of Patient Safety 16 September 2013 Portcullis House, London. The scale of the challenges. c58,000,000+ people. 140,000+ different ways the human body can go wrong. 6000+ medicines for treating diseases.
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Mike DurkinDirector of Patient Safety
16 September 2013
Portcullis House, London
140,000+ different ways the human body can go wrong
6000+ medicines for treating diseases
4,300+ ways of treating diseases
and we wonder why things go wrong….
National VTE Prevention Programme - collaboration of clinical experts, NHS leaders
and dedicated health professionals with the aim of ensuring that VTE prevention
strategies are fully integrated in to NHS systems and processes for the future
2010 - only 41% of patients were being risk assessed
Q1 2013/14 – 95.4% of admitted patients received a VTE risk assessment on admission
Significant reduction in VTE –associated mortality (unpublished draft data )
Data sourced from Hospital Episode Statistics (HES) for the period April 2007 – October 2012. The data is presented by rate (U prime chart) of patients with VTE per 10,000 Finished Consultant Episodes in inpatients in England. The numerator is calculated from a count of episodes of VTE recorded in any diagnostic position (diagnostic codes I80.1, I80.2, I80.3, I80.9, I82.9, I26.0, I26.9) by month. The denominator is the number of finished clinical episodes by month. The mean rate for the latest re-based period is 111.6 VTE’s per 10,000 FCE’s, an 8% increase from the first period centre line. There appears to be a seasonality effect in January (although it appears to a lesser extent in 2012). There is some evidence of this trend in the literature – partly explained by changes in coagulation factor levels – see http://www.ncbi.nlm.nih.gov/pubmed/19542893; http://www.ncbi.nlm.nih.gov/pubmed/22901545; http://www.ncbi.nlm.nih.gov/pubmed/21725580 . During the reported period there has been an increase (before and after, first (Aug-Oct) and last three data points) of 248,420 FCE’s.
% of patients with new VTE
The proportion of patients being treated for a new VTE: NHS Safety Thermometer
Overarching Indicators- selected to measure the breadth of each domain
i.e. the ‘comprehensive service’
Improvement Indicators- selected following analysis of multiple factors e.g. burden of disease, variation in quality , understanding what outcomes are most important to different groups e.g. children, working age adults, older people
Domain 5 of the NHS Outcomes Framework
Helping NHS England track progress towards achievement of improvement in Outcome Framework Domain 5 measures
NHS Outcomes Framework, indicator 5a: Patient Safety incident reporting7. NHS Outcomes Framework: domain 5
Past trends from 2007-2012
Aims for Improvement
Building Capacity through training, education, technical capability
Structural recommendations: Oversight, accountability and influence
Patient and Public Involvement
Measurement, transparency, tracking and learning
Legal penalties/criminal liability and their impact on safety
Implications for leaders at all levels
Staff and the work environment
1. Patient safety problems exist throughout the NHS: Like every other health care system in the world, the NHS experiences repeated defects in patient safety.
1. Recognise with clarity and courage the need for wide systemic change:
Our most important recommendations for the way forward envision the NHS as a learning organisation, fully committed to the following:
“You never get to safety through anger and blame. You get there through learning, curiosity and commitment”
“Systemsawareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love”