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Using the Mental Health Safety Thermometer

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Kurt Bramfitt

on 10 March 2015

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Transcript of Using the Mental Health Safety Thermometer

Using the Mental Health Safety Thermometer
to measure improvement
Kurt Bramfitt
@Kurtbramfitt

'harm
free
' care

Background
Iterative testing using PDSA

Operational definitions

Patient focused

Integrating measurement into daily routines

Immediate results - local, regional and national

Raising awareness of harms and changing mindsets

Social movement..a call to action for front line staff
The NHS Safety Thermometer
measuring ‘harmfreecare’ at the point of care
Its not just counting...it's caring
Design principles
Improvement over time
Measurement for improvement
Process measures collected locally
Setting the context
Violence and Aggression
In the UK, the National Audit of Violence found that a third of inpatients had been threatened or made to feel unsafe while in care [Royal College of Psychiatrists 2007].
Self-Harm
There is little or no general prevalence data of self-harm in mental health service users. The methods of self-harm can be divided into two broad groups: self-poisoning and self-injury. About 80% of people who present to emergency departments following self-harm will have taken an overdose of prescribed or over-the-counter medication (Horrocks et al.,2003).
Falls
Little prevalence data exists which relates solely to mental health services. Mental health units tend to combine a working age inpatient population with low risk of falling with services for older people with dementia who are at very high risk of falling, so rates are likely to be influenced by their balance of service provision.
Medication Omission
There are little or no unique prevalence data for medication omissions in Mental Health Services. Incidence data from NRLS for the period September 2006 to June 2009 indicate that there was a total of 1339 reported incidents of medication omissions, 183 of which resulted in harm to the patient. However this is widely believed to be an under-reported event.
Common Harms
What do we know from research?
49,047 suicides in England (2002 - 2012)

13,723 were mental health patients (28% of the total)

1,248 patient suicides per year
Suicide
576 homicides by patients in England in the period 2002-2012.

This represents 10% of the total number of homicides.
schizophrenia, affective disorder, personality disorder, alcohol dependence/ misuse and drug dependence/misuse
The UK has one of the highest self-harm rates in Europe, reported at about 400 per 100000 people (Horrocks et al, 2002).

It has been estimated that there are 170,000 self-harm presentations at hospitals each year in England (Kapur et al, 1998) and self-harm has been quoted as one of the five top causes of acute hospital admissions, but this greatly underestimates the problem since many people do not attend hospital.


53,273 individual service users admitted to hospital at least once in the year as a consequence of self-harm in 2021/13

Of these 56, 273 47% were already known to mental health services prior to 2012/13.

Figures taken from the ‘Mental Health Bulletin, Annual Report from MHMDS Returns, England - 2012-13’ published 26th November 2013 by the H.S.C.I.C

Self Harm
Homicide
16.6% of all incidents

Top harm categories are medication (23%), patient accident, which includes falls (20%), clinical assessment, which includes diagnosis and tests (17%), infrastructure, so buildings & beds (8%)

Measuring safety
224,504
And, this is just the tip of the iceberg...
Measures
Mental Health Safety Thermometer
Measuring:

-Self harm
-Violence and Aggression
-Psychological Safety
-Medication Omission
+
Acute services
: Restraint
Collection and Submission
Data
Improvement
Using the Mental Health Safety Thermometer for Improvement
Measure harm
Collect baseline data
Explore variation
Set improvement goals
Track improvement over time


Organisation A
Organisation B
Using the data and analysis tools
Organisation A
Organisation A
Organisation B
www.safetythermometer.nhs.uk
info.safetythermometer@nhs.net
Contact us..
Organisation A
Organisation A
Full transcript