The Harms


It is estimated that over 280,000 patient falls are reported every year, however the number of falls can be reduced using multifactorial assessments and interventions. The causes of falls are complex, particularly in the elderly, as they are linked to medical conditions including delirium, cardiac, neurological or muscular-skeletal conditions, medication problems with strength, balance or mobility. Poor eyesight or poor memory can all influence whether your patient is at risk of falling an injuring themselves.

Catheter Acquired Urinary Tract Infections

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney. UTIs are the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN).

Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.

Pressure Ulcers

As the most prevalent of the four areas of harm measured by the NHS Safety Thermometer, the significant impact of pressure ulcers in terms of suffering by patients, families and carers and in the wider NHS in respect of direct costs (4% of NHS budget) and staff time cannot be underestimated.

The elimination of avoidable pressure ulcers relies on each element of pressure prevention care processes being applied consistently. A number of resources and tools from various organisations have been brought together to support improvement work in each of these key elements which are:  

  • Risk identification 
  • Risk assessment 
  • Reliable implementation of all elements of the SSKIN bundle 
  • Initiating appropriate treatment 
  • Education for staff, patients and their families and carers.
Venous Thromboembolism

Since its recognition as the commonest cause of avoidable hospital mortality, reducing avoidable harm through the prevention of Venous Thrombo Embolism (VTE) has been an area of high national priority.

The consistent application of improvement methodology and reliable care process design, along with improved patient awareness and involvement, are key to achieving consistently high rates of VTE assessment and prophylaxis to assure sustainable reductions in hospital acquired VTE.


Medicines related error is one of the leading causes of harm to patients in a number of care settings. Medicines reconciliation is an intervention aimed at preventing errors due to medication discrepancies, resulting from defects in communication processes and care coordination at transitions in the patient care journey which are estimated to occur at least 50% of the time.

Omitted and delayed medication doses can lead to significant consequences for patients causing harm, prolonging recovery and lengths of stay. Recognized as a key part of an effective infrastructure designed to achieve ‘harm free’ care, a number of resources have been brought together to support the delivery of reliable processes of care that achieve for each patient, every time, a complete list of medication, accurately communicated.

Nutrition & Hydration

Correct hydration and nutrition can save lives; it is a key intervention relation to the four harms (Venous Thrombus Emboli (VTE), Falls, Catheter Acquired Urinary Tract Infection (CAUTI) and Pressure Ulcers).

Monitoring fluid status is essential basic care for all patients. Making sure that patients are adequately hydrated is one of the most important things that healthcare professionals can do to help prevent acute kidney injury (AKI). Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome.