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Queensland HealthPatient Safety: From Learning to Action III
Third Queensland Health report on clinical incidents in the Queensland Public Health System 2007/8
ACKNOWLEDGEMENTS I would like to thank all the organisations and individuals who made this report possible. This includes:
Ms Adele Gibson (Consumer Contributor)
Staff of the Patient Safety Centre
Staff of Queensland Health who have reported and managed incidents
Patients and consumer groups who have shared their experiences of the healthcare system
Queensland Health Patient Safety Officers, clinicians and others who have worked hard to promote patient safety within their health services
Healthcare leaders who have committed time and energy to patient safety improvement
Other partners and collaborators including the Australian Commission for Safety and Quality in Healthcare and the United States Veterans Health Administration National Centre for Patient Safety
Dr Jillann Farmer (Lead Author) Medical Director Queensland Health Patient Safety Centre Brisbane 2010.
Queensland Health Corporate Office 147‐163 Charlotte Street Postal Address: GPO Box 48 BRISBANE QLD 4001 Further copies of this document can be downloaded from the Queensland Health website: www.health.qld.gov.au ISBN 9781-921447-90-7 This work is copyright. It may be reproduced in whole or in part for study training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above requires written permission from Queensland Health. Queensland Health May 2010
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TABLE OF CONTENTS Foreword........................................................................................................................4
Consumer Foreword ......................................................................................................6
Executive Summary........................................................................................................7
The Queensland Health Patient Safety System – What is it and why are we still having adverse events?..............................................................................................7
What does this report tell us about patient safety in Queensland Health in 2007/8? ......................................................................................................................7
How is this information being used to improve patient safety for Queenslanders? 8
Key Programs and Initiatives .....................................................................................8
What does the future hold?.......................................................................................9
Introduction .................................................................................................................10
What is this report about?.......................................................................................10
Does this report measure patient safety? ...............................................................10
Some terminology to help with understanding this report.....................................10
Clinical Incident Management .....................................................................................17
The 2007/2008 reporting year in detail .......................................................................18
Significant Changes in 2007/2008 ...........................................................................18
Summary data from PRIME‐CI for 2007/2008.........................................................19
Sentinel Events and SAC1 events reported using the Reportable Incident Brief system......................................................................................................................19
Patient Harm in 2007/2008. ....................................................................................24
Three Years Change for Safety.....................................................................................26
A steady growth in incident reporting.....................................................................27
SAC 1 data From the Reportable Event Register .....................................................28
Increased reporting of no harm incidents ...............................................................28
Changes in Proportion of SAC 1, 2 and 3 events .....................................................30
Types of Clinical Incidents........................................................................................31
What do these changes mean? ...............................................................................33
Incident Analysis – How we learn and improve our systems ......................................35
Case 1: Death during transfer to another facility ....................................................36
Case 2: Death of a Baby ..........................................................................................38
Case 3: Suspected Suicide in the Community.........................................................40
Case 4: A Fall ...........................................................................................................42
The challenges of measuring “safety” .........................................................................45
Focus on high risk areas...............................................................................................46
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Falls Injury ................................................................................................................46
Pressure Ulcer Prevention .......................................................................................53
Mental Health ..........................................................................................................58
Other Patient Safety Programs ....................................................................................62
Haemovigilance: Queensland Incidents In Transfusion..........................................62
Clinical Handover .....................................................................................................63
The Clinician Performance Team.............................................................................63
Coronial Management .............................................................................................66
Ensuring Correct Patient, Correct Site and Side, Correct Procedure (3Cs) .............67
Infection Surveillance and Prevention.....................................................................68
The Informed Consent Program ..............................................................................69
Medical Fatigue Risk Management Strategy ...........................................................71
Management of aggression and other patient behaviours that can lead to harm.71
Medication Safety ....................................................................................................76
Open Disclosure Program ........................................................................................80
Patient Identification ...............................................................................................81
Recognition and Management of the Deteriorating Patient...................................83
Directions for future work ...........................................................................................84
Appendix 1: Procedures Involving the Wrong Patient or Body Part ...........................85
National context.......................................................................................................85
Queensland Health ..................................................................................................85
Description and analysis of 27 cases .......................................................................85
Extent of patient harm.............................................................................................87
Contributory factors.................................................................................................88
Compliance with four‐step safety protocol .............................................................88
Comparison with previous reporting period (2006/07 vs. 2007/08) ......................89
Appendix 2: Learning from Adverse Events................................................................93
Final Analysis Findings .............................................................................................93
Key priorities identified for each of the categories are listed below. .....................95
Future Recommendations Analysis .........................................................................97
Appendix 3: A review of the 2008 Mental Health Incident Analyses .........................98
Appendix 4: Strength of Recommendations..............................................................103
References .................................................................................................................104
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Foreword On an average day in Queensland Health:
7832 people receive admitted care in acute public hospitals including 1114 people who receive same‐day admitted care
29,372 non‐admitted patient services are provided in acute public hospitals
4096 emergency services are provided for non‐admitted patients in acute public hospitals
115 babies are born in acute public hospitals
1457 people receive residential care in 21 aged care facilities
461 callers are given qualified and supportive advice on health concerns through the health hotline, 13HEALTH (13 43 25 84)
$21.1 million is spent on public health services
$1.66 million is spent rebuilding and maintaining health facilities Queenslanders enjoy excellent health by world standards. We are justly proud of our healthcare system, which provides universal access to all residents, regardless of where they live. The vast majority of care delivered in our Queensland Health hospitals and health services is safe and effective. However, despite the excellent skills, training and best intentions of our staff, occasionally things do not go as expected. When this happens, particularly when the consequence is severe, it causes major distress for patients, families and staff. Publicity around these events can also lead to the community losing trust in their health system. Queensland Health recognises that patients have a right to the safest possible healthcare, and it is in everyone’s interest that we keep improving. The first step in addressing a problem is acknowledging that it exists. Queensland Health has worked hard to develop a culture that actively encourages staff to report clinical incidents, and sees these as an opportunity to learn about and fix problems, rather than ignoring them. Sharing information in an honest and transparent way is fundamental to improving patient safety and building trust in both the community and our staff. This report builds on the First and Second Queensland Health Reports on Clinical Incidents and Sentinel Events Patient Safety: From Learning to Action I (2007) and II (2008). At first glance, it would be easy to conclude that the 21% increase in staff reporting of clinical incidents since the previous year, represents a worsening of patient safety in Queensland Health. On the contrary, almost all of this change relates to increased reporting of near misses. This is exactly the change we are looking for. As the culture improves, staff report more as they become more confident that concerns
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will be addressed. The analysis of these incidents continues to help us better understand the root causes of incidents, and implement changes aimed at improving safety. Lessons learned from clinical incidents continue to inform the extensive Queensland Health patient safety improvement program. This Report summarises the major state‐wide patient safety improvement work led by the Patient Safety Centre and other state‐wide and local units devoted to addressing the major causes of preventable patient harm. This work is already delivering real improvements in patient safety. For example, improvements in pressure ulcer prevention over the last three years are saving an estimated 20,000 patients each year from this painful and preventable condition. With each pressure ulcer adding an average 3 days extra stay per patient, this equates to 60,000 bed days every year that are freed up for other patient care; the equivalent of a new 160 bed hospital. Queensland continues to be a national leader in the development of new patient safety initiatives that will lead to improved safety in the future. Initiatives such as the Children’s Early Warning Tool (CEWT) will support staff, particularly in rural hospitals, in rapid identification and management of sick children. Queensland Health is at the forefront of many such programs that aim to provide real support to staff at the bedside, to improve patient safety. Consumers of healthcare have a direct stake and active role to play in their own safety. Through partnerships between the Patient Safety Centre and the newly formed Health Consumers Queensland, I am delighted to see that consumers are becoming active partners in developing and implementing patient safety programs across the state. It is only right that consumers are involved in the preparation of this Report and I welcome the consumer foreword and comments. Whether you are a member of the Queensland community, or a staff member of Queensland Health, I hope this report achieves its goal of raising awareness of patient safety issues and what is being done to address them. Continued improvements in patient safety can only be achieved with the combined efforts of all that work in, manage and use the Queensland public health system. Dr John Wakefield Senior Director Queensland Health Patient Safety Centre
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Consumer Foreword To be a patient within any health environment means to make oneself vulnerable to the expertise of others. In that state of vulnerability, the extent of trust between all of those involved holds the key to patient safety. In a society where health systems have become fraught with problems, pressures and complexities, the only lasting solution for positive change lies in the forging of a solid partnership between those who seek health care, and those who plan, fund and provide it. The Patient Safety Centre is the ideal hub for that partnership. It was gratifying to represent Queensland at a national patient safety workshop recently, as a State that has shown extended initiative and commitment to the area of patient safety in the last few years. The Queensland level of support and dedication to this cause clearly equalled and excelled that of other States. During my involvement with the Patient Safety Centre over the last two years, I have watched closely as so much has been achieved through its work ‐ often providing a ray of hope upon a backdrop of negativity. A multitude of initiatives and specific projects, research and training, are supporting a healthier, safer culture in this State. With the foundations for firm partnerships between all stakeholders laid, the future looks infinitely brighter for consumers. Consistent support for the PSC and its endeavours, close and respectful partnerships between all concerned, all within an environment of openness and honesty, will ensure the continued positive progress of patient safety in Queensland. I am glad to have had the opportunity to participate in this, and I urge all consumers of health services in Queensland to support the Patient Safety Centre into the future. The only true waste in this life is the error not recognised and learnt from. Adele Gibson Consumer Representative Patient Safety Centre Advisory Committee 2007‐2009
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Executive Summary This is the third edition of "From Learning to Action". Queensland Health remains committed to transparency in sharing information about adverse clinical events. This report is therefore for all Queenslanders, but in particular, for the staff of Queensland Health and for members of the community who are interested in what Queensland Health is doing to improve patient safety. It is also for anyone who wants to share in, and benefit from, the things that we have learned as we have introduced a comprehensive Patient Safety System into Queensland Health.
The Queensland Health Patient Safety System – What is it and why are we still having adverse events? The Patient Safety System is made up of policies, processes and supporting tools that ensure we constantly learn from and prevent clinical incidents. More important, however, are the organisational culture and the people who make such systems work. Queensland Health’s Patient Safety System could achieve nothing without the vigilance and responsiveness of Queensland Health staff. Clinical incidents (adverse events and near misses/near hits) occur in every health system in the world. Sometimes, patients are harmed. Queensland has recognised this reality, and has responded by the development of the Queensland Health Patient Safety System. The goal of this system is to minimise preventable patient harm. We have not yet eliminated it, and that is why we continue to receive reports of adverse events. We are still quite early in a process that will take many years, but the gains to date are significant. Every time an incident occurs, we seek to learn from it and find ways in which to prevent its recurrence. It is only by having a system that allows us to recognise, report, analyse and learn from incidents, that we can improve and ultimately reduce preventable harm.
What does this report tell us about patient safety in Queensland Health in 2007/8? The most striking feature of the data in this report is that we have been successful in capturing reports of more clinical incidents than ever before, with our staff making 57,018 voluntary reports of clinical incidents using our clinical incident reporting system, PRIME CI. This represents an overall increase of 21.3% compared with the previous year, and an overall increase of 58% since the first "Learning to Action". Because these reports are voluntary ‐ that is, it depends on staff recognising and then making a decision to report, an increase in the number of reports is not a measure of an increase in actual incidents; rather it demonstrates the successful implementation of policies, systems and cultural reform that encourage staff to report problems. A 58% growth over 3 years in incident reports represents a fundamental cultural shift, and it is the single greatest predictor that we will succeed in a goal of minimising preventable patient harm. Encouragingly, incidents reported
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where patients were not harmed formed the bulk of the growth, with "no‐harm" incidents up by 28%, and a growth of "harm" events of just 1.8%. 77% of all reported incidents were not associated with patient harm. From 2006/2007 to 2007/2008, there was growth in hospital activity of 7.4% (combined admitted and non‐admitted episodes of care)[1]. The much lower relative growth in reported "harm" incidents (1.8% growth) is another positive indicator that our endeavours to improve safety are having an impact. The increase in reporting is spread relatively evenly across all primary incident types, with falls (n=11,648, up from 10,931 last year) and medication incidents (n=8920, up from 7,483) continuing to be the most commonly reported. 22.2% of reported incidents resulted in patient harm, with some types of clinical incidents more likely to cause harm. Falls are the number one reported cause of patient harm, accounting for almost 35% of all harm from reported events. There were 3,949 falls reported as resulting in patient harm during the 2007/2008 financial year. Pressure ulcers are also an area of significant concern, accounting for 12.6% of reported harm. This data provides clear evidence that these continue to be high risk areas, deserving of continued prevention effort.
How is this information being used to improve patient safety for Queenslanders? Merely collecting data about clinical incidents would be pointless without the underpinning analysis and learning. Significant effort goes into analysing what has occurred, why it has occurred, and what can be done to prevent recurrence. Appropriately, most effort goes into analysis of the most serious events. Root Cause Analysis is the preferred method of analysis for Severity Assessment Code (SAC) 1 events, with Human Error and Patient Safety (HEAPS) analysis providing another strong, system‐focussed analysis approach. Quantitative and qualitative data is available from PRIME CI, and extremely rich qualitative information flows out of analysis of SAC 1 events. Local management teams review lower category (SAC 2 and SAC3) events, using methods ranging from Root Cause Analysis to aggregated review. The local line managers have a key role in the identification and prioritisation of corrective actions for the incidents reported by their staff. PRIME CI data is increasingly providing a rich array of information about what goes wrong and how. The system is being continuously improved to allow better reporting, better analysis, and better data extraction. We now share de‐identified data internally and externally to further support patient safety improvement.
Key Programs and Initiatives Incident reports guide the prioritisation of our work to improve Safety. Accordingly, Patient Safety Centre and other key units within Queensland Health have continued to work in the following areas:
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Falls Injury Prevention Pressure‐ulcer prevention Mental health safety, including suicide prevention Blood transfusion safety Clinical handover Clinician performance Coronial management Ensuring correct patient, correct site and side, correct procedure (3cs) Infection surveillance and prevention Informed consent Medical fatigue risk management Management of aggression and other patient behaviours that can lead to
harm Open disclosure Medication safety 3 new priority areas:
o Clinical handover o Patient identification o Recognition and management of the deteriorating patient
What does the future hold? We will continue to build on the early work of the three new priority areas, as we move from concept and design to strategy implementation. In particular, we are now in a position to make use of the wealth of information available in our incident reporting and analysis. The first of those analyses are included as appendices to this report, and the coming year will see a further development of this type of work. We will continue to participate in collaborative, national projects in areas of high priority, and will identify the next round of new priorities upon which to commence work. It is likely that these will be drawn from the incidents reported as "Deviations from Planned Care", which are one of the largest subgroup of incidents. Each year, Patient Safety Centre provides this report, and each year, concern is raised that the increased number of reported incidents reflects an increase in harm. Because of the way in which incidents are reported, and the linkage between reports and a "safety‐conscious" culture, volume of reports are not a measure of safety performance. Patient Safety Centre is committed to the development of a suite of Patient Safety Indicators, by which safety can be objectively measured. We acknowledge that we will never completely eliminate harm from clinical incidents, but the learning and actions that flow from a robust Patient Safety System give us hope of achieving our goal of minimising preventable patient harm.
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Introduction
What is this report about? On one level, this is a report about the things logged into our clinical incident reporting system (PRIME CI) by the staff of Queensland Health. It provides a summary of the kinds of issues they have voluntarily reported, and a more detailed analysis of the serious events. This report is about the things that our staff have identified, reported, and acted upon. In the three years since we introduced a comprehensive incident reporting and management system, there has been a steady growth in reports. We are proud that our staff are proactively identifying and reporting incidents and risks. Nobody is better placed than front‐line staff to report these matters, and significant effort has gone into making it easier for them to report. Underpinning the reporting of incidents, however, is the transformation of patient safety culture. In just 4 years, Queensland Health has sought to establish a robust, transparent and accountable Patient Safety System. This report is also about the successes and challenges of that transformation.
Does this report measure patient safety? This report is not, and never has been a comprehensive catalogue of the good and bad in the health care system. Because it is compiled from voluntary incident reports, it cannot measure how safe the health system is, other than by the indirect positive link between reporting and safety cultures. This report describes the steps we are taking to make Queensland Health safer for patients, but it does not attempt to measure safety performance. One section of the report is devoted to examining the issue of measuring patient safety, because development of methods to measure our progress is now due. In the future, as we implement a valid, reliable suite of patient safety indicators1, they will be incorporated into subsequent reports. For now, the best measure of safety is in the evidence of cultural change and improved transparency.
Some terminology to help with understanding this report There are some core concepts that will assist in interpreting this data. An overview of the Clinical Incident Management System is a good place to start.
1 The World Health Organisation defines an Indicator as a variable with characteristics of quality, quantity and time used to measure, directly or indirectly, changes in a situation and to appreciate the progress made in addressing it.
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Reportable Incident Brief A Reportable Incident Brief (RIB) is a faxed document that districts send to the Patient Safety Centre to advise of a serious clinical incident. A RIB is completed for all Sentinel Events and all Severity Assessment Code (SAC) 1 events, in addition to the entry of information into the computerised reporting system (PRIME‐CI). Patient Safety Centre uses the RIB information to maintain a Reportable Events Register.
Clinical Incident Management System The Clinical Incident Management System defines our recognition of and response to adverse events. The system is summarised in the following Figure 1.
Figure 1: The Queensland Health Clinical Incident Management System
Patient Experience
Post Analysis Feedback
Clinician Disclosure
Formal Open Disclosure
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Clinical Incident A “clinical incident” is any event or circumstance which has actually, or could potentially, lead to unintended and/or unnecessary mental or physical harm to a patient.[2] A clinical incident is not necessarily a mistake or an error. Some clinical incidents occur simply due to chance – for example, a previously completely unknown allergy to a medication. We encourage staff to report all clinical incidents, not just those that they believe are due to error. The Quality in Australian Healthcare Study [3] showed that 70% of incidents were associated with human error, and 50% were not preventable with the knowledge available at the time of the study.
Clinical Incident Management Implementation Standard The Clinical Incident Management Implementation Standard (CIMIS)[2] sets out what Queensland Health does in response to Clinical Incidents. The organisational response varies according to the severity of consequence to the patient. During the reporting period, CIMIS 2006 was the version in application, and the descriptors and definitions used in this report below relate to that document (which has subsequently been superseded).
PRIME Clinical Incident (PRIME CI) PRIME CI is our clinical incident management information system. It is accessible from every networked computer in Queensland Health, and is available to all staff. It is also used by managers to read about and manage clinical incidents and record corrective actions for incidents that have been reported by staff in their area.
Clinical Incident Report A clinical incident report is a voluntary entry made by staff into our clinical incident reporting system, PRIME CI. We rely on our clinical staff to report incidents. This means that they are often reporting something to which they may have contributed. Every clinical incident report in our system has been voluntarily lodged by staff, and the vast majority have been lodged by front line staff involved in clinical care, when they do or witness something that has harmed a patient, or that could have harmed a patient. Where our staff become aware that a patient has died after leaving hospital, this is also often logged as a clinical incident particularly in the case of Mental Health, where suicide in the community is specifically defined as a "SAC 1 Reportable Event" (see below).
Severity Assessment Code “SAC” The Severity Assessment Code (or “SAC” rating) is the way in which we distinguish the most serious events from others. SAC ratings (based on the consequences to the patient of the adverse event) range from 1 to 3. SAC1 events are the most serious events, and are those where the patient has died, or has been seriously and permanently harmed. Examples of serious permanent
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harm include things like paralysis, loss of limb or limb function, or other permanent disability. The formal CIMIS 2006 definition of SAC 1 event is as follows: “Death(s) or permanent loss of function unrelated to the natural course of the underlying condition (includes defined Sentinel Event)”. SAC 2 events are defined as follows: “Patients with temporary loss of function unrelated to the natural course of the underlying condition. Includes increased length of stay or surgical intervention as a result of incident”. SAC 3 events are defined as follows: “Patients with minor or no injury. No increased level of care or length of stay”.
“Open”, “In Process” and “Closed” incidents An incident is reported by staff at the coalface, by logging on to any networked computer in Queensland Health. Once the incident is reported, it is given the status of “Open”. The incident management process requires that the manager (almost always a senior nurse or doctor) responsible for that work area then reviews the incident. This process can take as little as a few days, up to many weeks or months. The more serious the incident, the longer the analysis generally takes, because more sophisticated incident analysis methods are used. While the review is underway, the incident is given the status in PRIME CI of “In Process”. Once the analysis is complete, and all “corrective actions” (see below) are completed, the incident can be “closed”. Some corrective actions can be rapidly implemented, whilst some take months or even years to implement (e.g. capital works to improve the physical facilities of a health service). We do not close an incident until all of the agreed corrective actions have been completed. Only then is it reported as “closed”.
Incident Analysis This is the process by which we learn from reported incidents. The level of analysis is usually proportional to the severity of the incident. For the most serious incidents, we usually perform a “Root Cause Analysis” (RCA). An RCA is a quality improvement technique that explores the chain of events responsible for adverse events in order to identify the factors which caused or contributed to the event, as well as the measures that may be implemented to prevent or reduce recurrence of the same type of event. The objective of an RCA is to understand how and why an event occurred, rather than to apportion blame or determine liability. The intense and structured review of an RCA also often uncovers other, unrelated opportunities for safety improvement, and these are incorporated into the RCA report as "Lessons Learnt".
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RCA is a highly technical task, and is governed by specific legislative requirements (including release of the report). All RCA teams in Queensland are led by staff who have received training in this internationally recognised method of incident analysis. The Human Error and Patient Safety (HEAPS) method is an alternative analysis method used for incidents that are ineligible for, or do not require an RCA. HEAPS guides analysis teams to systematically examine the factors that may have contributed to the adverse event (patient factors, task factors, practitioner factors, team factors, workplace factors and/or organisational factors). Staff who lead this work have also usually received specific training. The vast majority of our incidents are analysed by front‐line healthcare workers and their line managers. For SAC 2 and SAC 3 incidents, line managers are able to work with their teams to rapidly identify and implement corrective actions where necessary, without the requirement for elaborate process. However, line managers have the option of requesting more detailed review if the issues are complex, or if there may be state‐wide lessons to be learned. The majority of line managers are capable of leading a HEAPS analysis if this should be considered necessary. Incident analysis is intended to work in parallel to, and not as a substitute for performance management, consumer feedback systems, staff complaints, professional standards regulation or legal processes (e.g., civil or coronial).
Corrective actions Corrective actions are the things that we do to change our workplace or work methods to reduce the likelihood that this type of incident will happen again. This might include things like introducing a new system for administering blood, running training for staff or making changes to a building. Corrective actions are not all equal. Some are more effective than others. Policies and procedures are often not the most effective way of making patients safer, because there is a limit to the amount of policy that a clinician can carry in his or her head, ready to deal with every eventuality. Education can be an effective remedy, but requires ongoing effort to achieve sustained change. Physical changes to the workplace such as improved equipment or workspace layout are the strongest corrective actions, most inclined to result in lasting protection. Executive managers have a key role in ensuring that wherever feasible, strong corrective actions are chosen. For more information about Strength of Actions, see Appendix 4.
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Harm We provide staff the option of recording whether they believe the clinical incident has harmed the patient. This is not an assessment of severity of harm, but gives a broad indication of how many events are being reported where staff perceive that a patient was hurt. “Harm” can range from a small skin tear all the way through to loss of life or limb. We collect data about severity of harm by using the SAC classification system, which is measured by the SAC code (see above),
Sentinel Events Sentinel Events are rare events, and are defined in a list endorsed by the Australian Health Ministers. The definitions (listed below in Figure 2) do not all contain reference to patient harm. However, the overarching definition of Sentinel Events requires that these events have associated consequences of death or permanent loss of function. They comprise only a small percentage of incident reports. Out of the total number of incidents reported in Queensland Health during the reporting period, fewer than 0.05% were Sentinel Events. Sentinel Events formed the basis of original reporting schemes. However, experience in Queensland demonstrated the limitations of the national list, and our incident reporting scheme expanded the definitions to capture more events. This was done to maximise reporting, and therefore increase our ability to learn and improve the healthcare system.
Figure 2: National Sentinel Event List
National Sentinel Event List Source: Australian Council for Safety & Quality in Healthcare.
1. Procedures involving the wrong patient or body part
2. Suicide of a patient in an inpatient unit
3. Retained instruments or other material after surgery requiring re‐operation or further surgical procedure
4. Intravascular gas embolism resulting in death or neurological damage
5. Haemolytic blood transfusion reaction resulting from ABO incompatibility
6. Medication error leading to the death of patient reasonably believed to be due to incorrect administration of drugs
7. Maternal death or serious morbidity associated with labour or delivery
8. Infant discharged to wrong family
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We collect data about Sentinel Events (and SAC 1 events) in two ways – electronically and manually. The dual data collection reflects the importance placed on these serious incidents. The electronic collection depends on the staff caring for the patient entering a report into the PRIME‐CI system. The manual system is activated by escalation of the incident to the District Chief Executive Officer (formerly District Manager), and entails a faxed notification (Reportable Incident Brief) to the Patient Safety Centre. Because the latter involves Patient Safety Centre review and discussion, where there is a conflict between the two sets of data, this report has made use of the manually collected data (called the Reportable Events Register).
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Clinical Incident Management The processes that staff and managers must follow are set out in CIMIS, as explained above. During the current reporting period, for Sentinel Events and other SAC 1 events, CIMIS 2006 required that a Root Cause Analysis be performed for all inpatient events, except in those cases where a Root Cause Analysis was not permitted by law. The District Manager could choose not to perform an RCA in some additional circumstances (for example, suicide in the community), but alternative analysis was always required. For SAC 2 and 3 events, lower levels of analysis were permitted, such as HEAPS (Human Error and Patient Safety), or clinical review by an appropriately qualified senior clinician or group of clinicians. Many SAC3 events are managed immediately by the line manager, with local actions allowing a rapid response. SAC3 incidents can be managed individually, or by aggregated review, which helps to identify themes. SAC definitions and required actions from CIMIS 2006 are set out below.
Figure 3: CIMIS 2006 Severity Assessment Code (SAC) definitions and required actions
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The 2007/2008 reporting year in detail
Significant Changes in 2007/2008 Queensland Health exists in a changing environment, and we are constantly seeking to improve the systems and processes for patient safety. Many such changes were implemented during the reporting period, but two in particular are worth noting, because of their impact on the way we work and on our data.
Legislation for Root Cause Analysis In May 2007, legislation was enacted to provide for robust analysis of serious adverse events. The legislation commenced part‐way through the current reporting year. The legislation implemented recommendations from the Health Action Plan [4] and the Health Systems Review [5], and has the effect of providing qualified privilege for the inner workings of Root Cause Analysis. This legislation mirrors similar provisions in other safety‐conscious industries, for example, the Transport Safety Investigation Act 2003 (which applies to aviation investigations). The net effect of this privilege is that the identity of the team is protected, information gathered by the RCA team cannot be used in other processes, and is not able to be obtained through legal process. The purpose of this protection is to allow staff to participate in or provide information to analysis teams, without fear that this information could be used in proceedings against them or a colleague. The legislation requires release of a report from the RCA, facilitating timely and full Open Disclosure. The RCA is often the first source of answers, with other processes (for example legal proceedings, coronial investigations, or professional regulation) sometimes taking many years. This impact of this legislation is due for evaluation during 2010.
Availability of SAC 1, 2 and 3 classification in PRIME CI The capacity for PRIME CI to capture information about SAC classification and whether or not the patient was harmed was introduced in the 2006/2007 year. The current reporting year reflects the first full year where this data has been available.
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Summary data from PRIME-CI for 2007/2008 The following section presents data that has been entered into the PRIME‐CI system by Queensland Health Staff.
SAC 1, 2 and 3 reports During the 2007/2008 reporting year, there were a total of 57,018 incidents reported. Of these, 0.4% (250 incidents) related to death or serious, permanent harm (SAC 1), and 3.5% (2,015 incidents) related to temporary, less severe harm (SAC 2).
Figure 4: Incident reports in PRIME‐CI by SAC category ‐ 2007/2008
Sentinel Events and SAC1 events reported using the Reportable Incident Brief system As noted above, we have two reporting options for Sentinel Events and SAC 1 events – staff report these in PRIME CI, but they also escalate them manually through the reportable incident brief system. There is a difference in the numbers collected for the two systems – PRIME CI records 250 SAC 1 events, whilst the Reportable Event Register records only 169 reported SAC 1 events. There are a number of possible explanations for this, including:
When CIMIS was first introduced in 2006, suicides were not routinely collected via the Reportable Incident Brief system. They were managed by Mental Health Branch, but staff still reported into PRIME. Some of this gap may be attributable to legacy practices.
The definitions for reporting as it applied at the time period captured by this report meant that deaths due to underlying clinical conditions were not reportable. It is possible that there have been episodes where the staff
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reporting through PRIME CI were unaware of the cause of death, but it became clear before the RIB was lodged that this was not a “reportable” event.
We have identified this as an unacceptable gap in the reporting system, and a PRIME CI system change from December 2009 will ensure that there is no discrepancy for reports lodged after that date. In the meantime, from July 2009, a monthly reconciliation between Reportable Events and SAC 1 Reported Incidents in PRIME CI has been instituted. Sentinel Events are rare events, and are defined in a list endorsed by the Australian Health Ministers. During the reporting period, all Sentinel Events were managed in the same manner as SAC 1 events, even if the patient was not harmed. There were 19 SAC 1 Sentinel Events (that is, the consequence of the Sentinel event was death or serious, permanent harm). Figure 1 shows the reported SAC 1 Sentinel Events for 2006/2007 and 2007/2008.
Figure 1: Sentinel Event Categories
2007/2008 Total SAC1
2006/2007 Total SAC 1
National Sentinel Event Number
(SE #) Deaths Perm’nt Loss of function
Deaths Perm’nt Loss of function
NSE 1 Procedures involving the wrong patient or body part 0 8 0 4
NSE 2 Suicide of a patient in an inpatient unit1 5 0 2 0
NSE 3 Retained instruments or other material after surgery, requiring re-operation or further surgical procedure
0 0 0 3
NSE 4 Intravascular gas embolism resulting in death or neurological damage
0 0 0 0
NSE 5 Haemolytic blood transfusion reaction resulting from ABO incompatibility
0 0 0 0
NSE 6 Medication error resulting in death of a patient reasonably believed to be due to incorrect administration of drugs
5 0 6 0
NSE 7 Maternal death or serious morbidity associated with labour or delivery (excluding neonates and babies)
0 1 0 4
NSE 8 Infant discharged to the wrong family 0 0 0 0
TOTALS 10 9 8 11
A detailed report about procedures involving the wrong patient or wrong body part is included as Appendix 1.
1Suspected suicide reports (Only the coroner can determine suicide as cause of death) under Coroners Act 2003.
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The sentinel event descriptors are quite restrictive, and are actually a small subset of clinical incidents that result in patient harm. Queensland Health has adopted a much more comprehensive stance on incident management, and requires the reporting of all SAC 1 events, even when they do not meet the definition of a National Sentinel Event. This means that we collect much more data about patient harm than we would under the pure Sentinel Event system.
Deaths reported using the Reportable Incident Brief system We collected information about 122 deaths that were not part of the national Sentinel Event Reporting Scheme. In combination with the 10 deaths that were reported as Sentinel Events, this comes to a total of 132 deaths reported as clinical incidents in 2007/2008.
Figure 6: Deaths reported using the Reportable Incident Brief System, 2007 ‐ 2008
Deaths
Suspected suicide on hospital premises of an admitted patient
5 Suspected Suicides
Suspected suicide in the community of patient under care of Queensland Health, or who has recently attended an Emergency Department
29
34
Maternal death associated with labour or delivery 0
Procedures Involving wrong body part 0
Medication event 5
Fall 7
Pressure Ulcer 0
Perinatal (Infants) 21
Complications 18
Diagnosis 18
Inter‐hospital retrieval/transfer
3
Investigations 1
Observations 5
Transfer of Care 7
Other Deaths
General Clinical Management
Treatment 13
98
Total 132 132
Suspected suicides are a major source of patient harm, accounting for over 25% of deaths reported as clinical incidents. We do not only collect data about suspected suicides in hospital – suspected suicides of patients under our care in the community, or who have recently been seen in an emergency department are also recorded.
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Figure 7: Suspected suicides as a proportion of all deaths reported using the Reportable Incident Brief System
In‐Hospital Suicide
5
4%
Suicide outside Hospital
29
22%
Other Deaths9874%
Queensland Health’s initiatives in Mental Health and suicide prevention are discussed in detail later in the report.
Serious Harm reported using the Reportable Incident Brief System Just as we collect more data about deaths than is required by the national sentinel event list, we also collect additional data about serious harm. Figure 8 provides detail of all the serious harm events that were reported using the Reportable Incident Brief system during 2007/2008.
Figure 8: All Serious Harm (SAC1) events reported using the Reportable Incident Brief System
Severe Harm ‐ Not death
Attempted Suicide on hospital premises of an admitted patient
0 Attempted Suicides resulting in severe harm
Attempted Suicide in the community of patient under care of Queensland Health, or who has recently attended an Emergency Department
1
1
Serious Maternal morbidity associated with labour or delivery
1
Procedures Involving wrong body part 8
Medication event 0
Fall 0
Pressure Ulcer 0
Perinatal (Infants) 5
Complications 7
Diagnosis 6
Inter‐hospital retrieval/transfer
0
Investigations 0
Observations 1
Transfer of Care 2
Other incidents resulting in severe harm
General Clinical Management
Treatment 6 36
Total 37 37
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Analysis of SAC 1 events CIMIS 2006 specified that Root Cause Analysis was mandatory for Sentinel Events and SAC 1 events, with certain exceptions. Mental Health services may choose to perform an alternative form of analysis (such as HEAPS) for suicides in the community. The Health Services Act 1991 specifies that an RCA may not be undertaken in circumstances where there is a prima facie “blameworthy act”. A Blameworthy act is defined in s38O of the Act as an intentionally unsafe act, deliberate patient abuse or conduct that constitutes a criminal offence. The Act also prohibits commissioning an RCA where there are reasonable grounds to believe that the capacity of a person who was directly involved in the provision of the health service during which the reportable event happened was impaired by alcohol or other drugs. In addition to these prohibited circumstances, there are other circumstances where an RCA may not be appropriate. For example, as RCA focuses on identifying systemic factors that contributed to an event, it is not an appropriate tool to investigate matters concerning the competence of individuals providing health services. These events are still subject to analysis, but not by RCA. In almost half of those SAC1 events where RCA is not commissioned, the HEAPS analysis method has been used. During the reporting period, 56% of SAC 1 events were reported in PRIME‐CI as having had an RCA undertaken, and a further 23% had a HEAPS analysis.
Figure 9: Analysis methods of SAC 1 events as recorded in PRIME‐CI
RCA141 56%
HEAPS58 23%
Local Clinical Review45 18%
Not Specified in PRIME‐CI
6 3%
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Further information from the analysis, learning and actions relating to SAC1 events is provided in the later section on incident analysis which takes a more in‐depth look at deaths of Queensland Health patients.
Patient Harm in 2007/2008. 2007/2008 represents the first year of full data where our staff have had the capacity to advise if the patient was harmed or not. Of the total number of reported clinical incidents, 78% were reported as involving no harm to the patient.
Figure 10: Total incidents (SAC 1, 2 and 3) and Harm ‐ 2007/2008
12,66522%
44,35378%
Harm
No Harm
Of the 12,665 “harm” incidents, 249 (2%) resulted in death or serious permanent harm, 2015 (16%) resulted in temporary loss of function, and 10,401 (82%) resulted in minor harm. SAC 1 and 2 incidents, by their definitions, are events where patients are harmed. The degree of harm is specified in the definitions, outlined in the introduction to this report. Rarely, an incident may be reported as a SAC 1, because it met the definition of one of the sentinel events, but the patient was not harmed. There was one SAC 1, no harm event in 2007/2008, where a deciduous (milk) tooth was removed by mistake. As this was a “wrong site surgery”, it meets the definition of a sentinel event, but because the tooth was going to fall out anyway, the staff who reported it classified it as “no harm”. All other SAC 1 events (n=249) and SAC2 (n=2015) were reported as “harm”.
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Figure 11: “Harm” incidents 2007/2008: Harmful incidents subclassified by SAC category
SAC 12492%
SAC 22,01516%
SAC 310,40182%
SAC 1
SAC 2
SAC 3
The data where the harm/no harm categorisation is of most use is in understanding the SAC 3 data, because by definition, all SAC1 and SAC2 incidents involve harm. SAC 3 incidents can be minor harm (such as a bruise), or no harm, for example, where staff identify and intercept an event before it causes any harm at all. In the full 12 months data of 2007/2008, 81% of the reported SAC 3 incidents were in the “no harm” category.
Figure 12: SAC 3 incidents and Harm ‐ 2007/2008
10,40119%
44,35281%
Harm
No Harm
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Three Years Change for Safety This is the third edition of “From Learning to Action”. Our processes and systems have evolved during that time, and we have been focussing on improving the overall patient safety culture of Queensland Health. It is easy to talk about improving culture, but what does this actually mean? Lucian Leape[6] has recently proposed six “major changes” for building a safety culture in healthcare:
Figure 13: Leape's Major Changes for Safety Culture
Leape’s “Major Change” Queensland Health Change We need to move from looking at errors as individual failures to realizing they are caused by system failures.
Human Error and Patient Safety Training and analysis tools
Root Cause Analysis legislation We must move from a punitive environment to a just culture. We do not punish for errors, but we do not tolerate misconduct.
Clear definition of “blameworthy” acts Introduction of non‐disciplinary pathway
for medical performance concerns
We move from secrecy to transparency. Instead of hiding errors, we discuss them and learn from them. Patients are honestly and completely informed of their care and when problems arise. Similarly, we are open to the public. We have no right to hide what we do. In a safe culture, transparency and openness are part of everything we do.
Publication of “From Learning to Action” Open Disclosure Program Clinical Incident Reporting System
Care changes from being provider centred to being patient‐centred.
Informed consent program
Open Disclosure Program
We move our models of care from reliance on independent, individual performance excellence to interdependent, collaborative, interprofessional teamwork.
Human Error and Patient Safety (HEAPS) training and tools
Team‐based training such as Crew Resource Management (CRM)
Accountability is universal and reciprocal, not top‐down. At every level, we are accountable – we take responsibility for safety – for all aspects of safety, and we expect those above us to do so as well.
CIMIS defines accountability for incident management from bedside clinicians right through to the Director General
Incorporation of safety measures into District CEO agreements.
Incident Reporting system Reporting and follow‐up of corrective
actions
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We provide this report each year because transparency is such a critical element in the transformation to a safe culture. We report the growth in reported incidents, knowing that this will be interpreted by some as a sign of worsening safety. Any harm to a patient is a result of a system failure. Creating an environment where our staff report to us, and where we in turn disclose to the public, and use this information to improve, is not a failure. It is the first, critical step in reforming the system to reduce harm. We have made significant progress against Leape’s six major changes, but the work is not yet complete. This report, viewed in tandem with its predecessors, clearly marks out that progress.
A steady growth in incident reporting The most striking feature of the three editions of “From Learning to Action” is that the number of incidents reported has gone up each year. When we first started collecting state‐wide data in July 2005, there were 2333 incidents reported in that month. In the month of June 2008, there were 5202 incidents reported. This growth in reported incidents is consistent with experience in other newly‐introduced reporting systems in Australia and internationally – growth in the number of incidents voluntarily reported by staff is expected as they learn how and when to report, and grow in confidence that reporting is worthwhile, and leads to change for the better.
Figure 14: PRIME‐ CI Total Monthly Reported Clinical Incidents July 2005 to June 2008
‐
1,000
2,000
3,000
4,000
5,000
6,000
Jul‐05
Sep‐05
Nov‐05
Jan‐06
Mar‐06
May‐06
Jul‐06
Sep‐06
Nov‐06
Jan‐07
Mar‐07
May‐07
Jul‐07
Sep‐07
Nov‐07
Jan‐08
Mar‐08
May‐08
Reported Incidents
Month
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SAC 1 data From the Reportable Event Register The definition of a “SAC 1” event in CIMIS (2006) is “Death(s) or permanent loss of function unrelated to the natural course of the underlying condition”. Our management of these 2 outcomes is identical, and they are generally analysed in the same way, and reported together. The graph below shows the relative proportions of each category of SAC 1 event over the last 3 years.
Figure 15: 3 Years of SAC 1 reports to the Reportable Events Register
2005/2006 2006/2007 2007/2008
Permanent Loss of Function
13 53 37
Deaths 149 104 132
149
104132
13
53
37
0
20
40
60
80
100
120
140
160
180
Reported SAC 1 Incidents
The increase in deaths from 104 to 132 since the previous reporting year is a significant concern. Analysis has shown that there have been increases in reports relating to deaths that would previously have been accepted as "expected" (although tragic) outcomes. For example, there has been growth in the reporting of deaths from recognised complications of treatment. One reason may be a cultural shift in considering whether such deaths were preventable and therefore appropriate for reporting and analysing as clinical incidents.
Increased reporting of no harm incidents We have 23 months of data regarding staff categorisation of incidents as “harm” or “no harm”. “Harm” data is not available for the 2005/2006 year of reporting, as this feature of the reporting system was not introduced until August of the 06/07 year. Of particular note is the growth in “no harm” incidents, with a 28% increase compared to the previous reporting period. This indicates that staff are reporting incidents where they believe we can learn, even when patients are not harmed. We call these incidents "near misses" or “near hits”. Because we only have 11 months of data for the 06/07 year, we have included the same period from the current reporting year, so as to have equivalent data for comparison. The graph below shows Harm and no Harm incidents, August to June for both 06/07 and 07/08.
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Figure 16: 11 Months of Harm and No Harm incidents, 06/07 and 07/08
11,456 11,659
31,71940,795
0
10,000
20,000
30,000
40,000
50,000
60,000
August 2006 ‐ June 2007 August 2007 ‐ June 2008
No Harm
Harm
“No Harm” incidents are events where no patient is harmed, but staff believe that these are worth reporting in order to keep other patients safe in the future. This reporting of no‐harm incidents creates a data repository of areas of potential harm which can be used to guide our efforts in future harm prevention. The strong growth in the reporting of “no‐harm” (up 28%) incidents suggests that our staff understand and value the process of clinical incident management. The growth of just 1.8% in “harm” incidents (11,659 up from 11,456) compares favourably with the growth in hospital activity over the same period (7.4% growth in combined admitted and non‐admitted episodes of care)[1]. Furthermore, the "harm" classification gives no indication of the degree of harm. To more fully understand the degree of harm caused to patients, it is necessary to examine the Severity Assessment Code data in conjunction with the “harm vs. no harm” data. There has historically been an anomaly between harm and the reporting requirements for National Sentinel Events. This has been the subject of a submission by Queensland Health to the Australian Health Ministers Advisory Council in 2009, and it has now been agreed to remove the requirement for reporting events where there has been no harm, in order to avoid misinterpretation of data.
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Changes in Proportion of SAC 1, 2 and 3 events PRIME CI had the ability to collect information about SAC classifications from January 2007, providing six months of data from the 06/07 year available for comparison. In order to simplify this comparison, the corresponding six months from the current reporting period were used. There is a full 12 months data presented elsewhere, but here, because we are seeking to compare with the previous year, we have used only six months data.
Figure 17: Six months of SAC classification data ‐ 2007 & 2008
SAC 1 SAC 2 SAC 3
2007(Jan ‐ Jun)
120 1,104 22,720
2008(Jan ‐ Jun)
141 1,048 28,786
0
5000
10000
15000
20000
25000
30000
35000
Reported incidents
Figure 18: Relative proportions of SAC 1, 2 and 3 incidents:
Jan - Jun 2007 Jan - Jun 2008 SAC 1 0.50% 0.47%
SAC 2 4.61% 3.50%
SAC 3 94.89% 96.03%
Total 100.00% 100.00%
This data reinforces the earlier impression that the bulk of growth in reported incidents has been in the no harm category. The raw numbers of SAC 1 reports increased (120 to 141) in the six months comparison period, SAC 1 incidents as a proportion of all incidents reported actually fell (0.5% to 0.47%). By contrast, SAC 3 incidents grew both in raw numbers (22,720 to 28,786) and the proportion (94.89% to 96.03%). This data provides some reassurance that the growth in reported incidents does not reflect a deterioration in the levels of safety, but is rather a measure of a greater willingness to report.
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Types of Clinical Incidents As in previous years, falls continue to be the most frequently reported adverse event, followed by medication, deviation from planned care and patient aggression/behavioural factors.
Figure 19: Top 10 Clinical Incidents Reported 05/06 – 07/08 (Includes Harm & No Harm)
0
2500
5000
7500
10000
12500
Fall
Medication
Deviations from Planned
Care
Aggression
Behavioural
Documentation
Pressure Ulcer
Treatm
ent
Equipment / Therapeutic
Device
Pathology Testing
Other (Not in Top 10)Reported Clinical Incidents
Primary Incident Type
2005/06 2006/07 2007/08
Since 2006, we have also collected data on which incidents have harmed patients. Some incidents are more likely than others to result in patient harm. The graph below shows the percentage of each category that have been classified as “harm” incidents.
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Figure 20: Percentage of Reported Incidents resulting in Harm by Incident Type
0%
10%
20%
30%
40%
50%
60%
Pressure Ulcer
Fall
Deviations from
Planned Care
Treatment
Diagnostic Procedures
Equipment /
Therapeutic Device
Infection
Behavioural
Perioperative
Procedures
Other
Percentage
of reported incidents that
resulted in Harm
2006/2007 2007/2008
The Sentinel Events have the highest likelihood of resulting in harm, at 94.9%. Pressure ulcers result in harm in 47.8% of patients, and falls in 37.3%. By contrast, 5.8% of medication incidents result in harm. This translates into a picture where the most frequent reported incidents are not the most frequent causers of harm. When only those incidents where harm has occurred are included, the falls, pressure ulcers and deviations from planned care dominate the picture. Falls account for almost 35% of all patient harm from reported adverse events. The combination of falls and pressure ulcers add up to almost 50% of events reported where patients were harmed. More detail is presented later in the report, in a dedicated section about our initiatives and progress in falls and pressure ulcers. The category of “injury” was discontinued in the current reporting period, and this is the reason for the high “other” in the 2006/07 reporting year.
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Figure 21: Percentage of total harm caused by incident types ‐ 06/07 & 07/08
0.0%5.0%
10.0%15.0%20.0%25.0%30.0%35.0%40.0%
Fall
Deviations from Planned Care
Pressure Ulcer
Behavioural
Treatment
Equipment / Therapeutic Device
Aggression
Medication
Sentinel Event
Perioperative
Procedures
Other
Percentage
of total harm caused by incident
type
2006/07(Aug ‐ Jun)
2007/08(Aug ‐ Jun)
This data gives us some guidance about where in our system effort should be focussed if we are to be effective in preventing harm.
What do these changes mean? Do these changes (particularly increased reporting) mean that the system is getting worse? On the contrary, increased reporting of errors is strongly correlated with better safety culture and better patient outcomes [7]. The growth in incident reports (most notably, the reports where there was no harm to the patient) reflects a positive growth in the engagement of Queensland Health staff in identifying and reporting risks to patient safety. It also demonstrates the success of the efforts made to have incident reporting become a normal part of the work of our staff. Understanding the implications of increased incident reporting requires an understanding of what drives incident reports. Other high‐hazard industries have implemented incident reporting systems well before health, but it is only recently that an evidence base has developed to demonstrate that the same factors influence reporting in healthcare as in, for example, aviation.
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Some of the factors known to increase incident reporting include: Degree of harm to patient; Knowledge about how to report [8]; A non‐punitive approach to error; Hospital management support for patient safety; [9] Feedback to reporters of incidents [10]
Queensland Health has actively sought to increase incident reporting by the introduction of the following measures: easy access to PRIME CI – there is an icon on every networked computer in
Queensland Health Deployment of specially trained Patient Safety Officers into every district, to
train and support staff in incident reporting and management Clear policies and procedures around incident reporting and analysis Clear organisational statements and management support of a just culture Introduction (in March 2008) of legislation to support Root Cause Analysis.
Our goal has been to improve the staff confidence that reporting incidents will lead to improvements. The steady rise in reports lodged by our staff shows that we have been, without doubt, successful in achieving that goal.
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Incident Analysis – How we learn and improve our systems Each edition of “From Learning to Action” has reported that the Patient Safety System is making Queensland Health safer for patients by nature of organisational learning. Patient Safety Centre has recently performed a review of the Root Cause Analyses conducted on events that occurred during the whole of 2008. Although that period is different from the reporting period covered by this edition of “From Learning to Action”, the results are highly likely to be indicative of results more generally. The results of that analysis are included as Appendix 2. Root cause analyses were performed in 141 SAC 1 events, but also in a number of lower category events. Districts can choose to perform an RCA in SAC 2 or 3 events, if they believe that there is something to learn, which will help prevent serious patient harm. It should be noted that the legislative provisions conferring privilege onto RCA do not apply for RCAs carried out into lower‐category events.
Figure 22: Final Analysis Types
Final Analysis Type for All Incidents Entered in PRIME‐CI between 01/07/2007 and 30/06/2008
Current SAC Rating
Root Cause Analysis
Heaps Analysis
Local Clinical Review
Local Line Manager Review
Grand Total
SAC 1 141 58 45 6 250
SAC 2 8 213 268 1526 2015
SAC 3 11 190 3179 51373 54753
Grand Total 160 461 3492 52905 57018
Analysis Case Studies Analysis of aggregated data is one way of looking at Root Cause Analysis. However, behind many RCAs is a heartbreaking narrative of system failures. Here, we provide the story behind just 4 of the SAC1 incidents that have occurred as a result of clinical incidents. Patient confidentiality and the Health Services Act 1991 prohibit us from fully publishing the entirety of this material. However, 4 de‐identified case studies are presented here, to demonstrate how recommendations are developed from the analysis of serious adverse events. Details not relevant to the incident or findings have been altered to protect patient privacy.
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Consumer Commentary:
Consumers in rural or remote areas should not have to settle for less: less experience, less supervision, less competence or less participation in decisions around transport. We need to be able to trust the health professionals who are treating and advising us. Changes which increase our participation in decisions about treatment and transport, and involve our families too, will increase our trust and feeling of safety during transport. When things go wrong, we need to know that investigations will be thorough, timely and result in positive change, because then our loss and suffering has meaning.
Case 1: Death during transfer to another facility
What happened? A 51 year old male patient presented to a small rural facility with a 24 hour verbal history of vomiting, diarrhoea and generalised weakness. He had been generally unwell for some weeks but had only sought medical assistance the day before at the local General Practitioner. The notes from the General Practitioner were not available to the treating team at the hospital. On the day of presentation a busy outpatients clinic was in progress and only one Medical officer was in attendance while the Emergency Room (ER) was staffed by one registered Nurse. Initial assessment was made by the Medical Officer and intravenous fluids were commenced with a plan of fluid resuscitation for dehydration on a background of gastroenteritis. Routine observations were commenced and the patient continued to be observed in the ER. Throughout this time he was alert and interactive despite being increasingly unwell. Over the course of 5 hours the patient gradually deteriorated until it was decided that he required transfer to another facility with a higher level of service capability. Calls for assistance from the Medical Officer were complicated by the lack of local senior supervision and the distance required to be travelled for more senior intervention and definitive treatment. The decision was taken to transfer the patient by road a distance of approximately 130 kilometres. Unfortunately during the transfer the patient significantly deteriorated and suffered a cardiac arrest in transit. Resuscitation attempts were not successful and he died on arrival to another facility. The case was reported to the coroner and is awaiting inquest.
The Root Cause Analysis identified the following factors: There is a shortage of suitably experienced medical relievers for smaller rural areas in Queensland Health. This creates a situation where junior medical graduates are sent to rural facilities for short term relieving
Junior medical staff don’t always have access to direct or immediate supervision, and this can lead to situations where the junior doctor overlooks critical clinical information. Even when they do recognise the situation, it is sometimes unclear when or how they should escalate their concerns.
There is no formalised early warning or flagging system to ensure appropriate contact with a senior clinician or Queensland Clinical Coordination .
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The rural preparation course cannot comprehensively prepare junior medical staff for the inherent challenges of rural and remote placements.
Lessons learnt : These are observations by the RCA team where there is scope for system improvement, but they are not thought to have contributed to the event being analysed.
a. There are no state‐wide standardised guidelines for minimum equipment set for transport/ retrieval packs.
b. Use of retrieval packs and the appropriate equipment is not well understood by general nursing and medical staff.
c. The layout and equipment available in Ambulances is not well understood by general nursing and medical staff.
d. There is not a standardised pharmacy list for a small rural facility. This is determined by the medical superintendent.
e. Formal standardised orientation package for medical officers need enhancing.
Recommendations: The RCA Team recommended that:
1. Only appropriately skilled clinical staff should be rostered for rural relieving. This would in practice mean that staff would only be considered for rural relieving if they have completed two terms in emergency where practical.
2. A formalised system for clinical oversight and support be developed and implemented within the district. This would include a clearly predetermined supervisor who would act as a local contact and mentor.
3. The training and preparation of rural relieving doctors could be improved. At a minimum this could include increase the content and length of the rural preparatory workshop, and a minimum of 2 terms of emergency medicine.
4. A structured process for the liaison of districts with the Queensland Clinical Coordination service be developed and implemented.
Open Disclosure: This case presented some significant challenges for the district in regard to the Open Disclosure process. The remoteness of the facility and the lack of local specialist medical staff it difficult to schedule and facilitate the process in a timely fashion in order to respond to the family’s needs. The outcome of the discussion with the family was that they were thankful for the opportunity to be heard as part of their grieving process but also for the frank and honest way that the team shared what had happened and what was planned to prevent recurrence. Importantly they were not abandoned by healthcare in the search for answers and commented that they found the assistance given by the district staff in regards to making further enquiries and complaints extremely beneficial during their time of grief.
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Discussion: This case has highlighted the need for improved preparation for and supervision of rural relieving by junior medical officers. The difficulties experienced in this district are not uncommon in a large decentralised state where long distances make the management of complex presentation to small rural facilities even more challenging. The need for early recognition and escalation to seniors for definitive treatment and transfer is amplified in situations where junior staff are functioning with limited supervision and clinical resources that are significantly less than they previously experienced. Open Disclosure is a critical element to an effective clinical incident management strategy. The application of a defined and clear method of approach provides administration and clinical staff with a useful and responsive way of dealing with patients and families in an honest and dignified way.
Case 2: Death of a Baby
What happened. A 9 month old baby girl had a history of a serious heart abnormality (present from birth) that was treated with cardiac surgery. The baby was taken by the family to a general practitioner at 11:25 am on a weekend morning. The GP wanted the baby to go directly to the hospital. This did not happen – the parents had understood that they were to go to the hospital if their baby “got any worse”. They did not read the GP’s letter, as it was placed in a sealed envelope. Just over 12 hours after seeing the GP, the baby was brought to the emergency department (at 23:56). It was a busy weekend night. The roster at the hospital had no emergency consultants on at this time of day. On arrival at the hospital the baby was seen immediately by a registrar with little paediatric experience. A diagnosis of dehydration was made and a treatment plan was made to insert an intravenous line and commence fluids. Insertion of the IV failed and the paediatric registrar was called. Both registrars were relatively junior and neither had received paediatric advanced life support training. Attempts were made to insert a nasogastric tube and re‐hydration was attempted via this method. At 0100 hours the infant went into cardiopulmonary arrest, an intra‐osseous needle was inserted yet despite attempts at resuscitation the baby died at 01:30hours.
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Consumer Commentary
Not all of us have the same ability to communicate with health professionals, and communication is the most important part of diagnosis and treatment. Identifying language problems and disabilities is the first step towards making communication more accessible to all consumers. Health‐providers need to be aware that their role includes making information, advice and instructions clear and accessible to all of us. Processes put in place to safeguard communication and prevent misunderstandings will make consumers feel more trusting of the system.
The Root Cause Analysis identified the following factors; An absence of point‐of‐care decision making tools‐
particularly paediatric hydration assessment, and measures to re‐hydrate including indications for intra‐osseus infusion.
Training factors related to Paediatric Advanced Life Support training among emergency and paediatric registrars.
Minimum observations requirements according to triage category level to monitor patient status.
There were lessons learnt around: Interpreter services engagement in the department.
Communication factors between hospital and GP.
Rostering practices around consultant cover for the department.
Management of clinical incident reporting and death review processes.
Recommendations: A recommendation was made to purchase PEMsoft (Paediatric Emergency Medicine decision support software) for installation on emergency department computers. This software had already been recommended as the result of another adverse event, but had not yet been implemented. It was subsequently approved and later supported state‐wide. It is now supported as an enterprise program on the Clinicians Knowledge Network portal of the Queensland Health intranet. A recommendation to provide training for registrars in Paediatric Advanced Life Support (PALS) was made and the district developed a local course for medical and nursing staff. Minimum observations requirements and frequency by triage category were documented and put into emergency department documentation procedure. Audits continue to be undertaken by the department’s own nursing staff as a measure of the department’s quality activities to demonstrate compliance.
Open Disclosure: A meeting was held with the family at the completion of the RCA. A senior clinician from the emergency department and from the paediatrics department worked through the process with an open disclosure consultant. The disclosure process involved more time in listening to the family and acknowledging the impact for them and the other children. The clinicians detailed where and how the service will be improved. Final details were also resolved for the family and the hospital about each
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other’s understanding of events and when they occurred. Additional social work support was identified and provided after the disclosure.
Discussion: This tragic death of a 9 month old baby girl is one of the most distressing types of events that we deal with. This death confronted us with consequences of the gap in training and tools that our front‐line staff were enduring. The rollout of PEMSoft, the increase in training, and changes to observation and rostering practices have all contributed to creating a reduced likelihood that this sequence of events will ever happen again.
Case 3: Suspected Suicide in the Community It is easy to assume that all incidents resulting in death are a result of significant failures, poor management or critical omissions. The following case study shows how some event occurs even when there have been no errors.
What happened A man in his early 40’s, presented to an emergency department with suicidal ideation, anxiety and panic attacks. Symptoms included feeling helpless, hopeless and “life not worth living”. He denied having plans to follow through with suicide. He was admitted as an inpatient, with a high suicide risk. He was placed on 15 minute clinical observations. Over the course of the admission of 7 days, he denied thoughts of self harm or of harming others, although anxiety was evident. He was supported to apply relaxation techniques with the expectation that he would work with a counsellor post discharge to manage his anxiety and panic attacks. Follow‐up arrangements with community based health professionals were put in place for the day after discharge. Two days post discharge, this man was found deceased at his home – suspected suicide.
Analysis (HEAPS) Root Cause Analysis is not mandatory for suspected suicides in the Community. A HEAPS analysis was performed. This looks at potential contributions to the outcome from patient, task, practitioner, team, workplace and organisational factors. The team found that the treatment options for this man were based on sound clinical decision making. In particular being admitted for 7 days; being regularly reviewed by appropriately trained medical staff; appropriate interventions by nursing and allied health staff during the inpatient stay; and follow‐up arrangements made in collaboration with the patient. The treating team consisted of a variety of disciplines who had clearly defined roles and adequate communication.
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Consumer Commentary:
Mental health consumers often have the experience of not being heard and/or believed. We will benefit from greater consistency and attention to information by service‐providers. Particularly in the areas of observations and documentation, improvements will increase our safety, where they have been traditionally subjective and patchy. Likewise, increased efforts to safeguard our health when we transition back into the community in terms of a support system, will logically reduce the risks of suicide and other self‐harm to the consumer.
There was little involvement of the family in the care at the patient’s request. The standardised suite of clinical documentation procedures are expected to be used in this setting. Some aspects of the documentation did not meet the standards, with some entries being difficult to read and others without date, time and designation clearly stated. Whilst it was not clear that anything within the hospital’s capacity would have prevented the suicide, there were still identified areas where the service could improve.
Recommendations 1. There should be more stringent inclusion of family members
or carers in the management plan of mental health patients. Where there is an issue regarding the veracity of the relationship, further investigation is required to identify the primary carers.
2. Documentation needs to be clear, comprehensive and concise. Entries in the patient’s charts needs to be dated correctly, with a time, date and the name and designation of the author written clearly. Education regarding correct, clear and precise documentation should occur on a regular basis. An audit of 10 charts per month should occur to identify improvements in documentation.
Discussion Good mental health care balances the self‐determination of patients (including respecting their wishes and life choices) with clinical goals around symptom management, relapse prevention, rehabilitation and general safety and well being. With hindsight, it seems that a greater effort to identify positive social supports and networks may have averted his untimely demise. This type of retrospective review provides some insight into the variety of stressors that can face people in their day‐to‐day life; and potentially provides a lesson regarding collection, analysis and interpretation of stressors for those at risk of suicide. Suicides in the community account for over 20% of deaths reported as adverse events. This case illustrates that while the preventability
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Consumer Commentary:
From a consumer perspective, falls are one of the most preventable causes of patient injury in existence. Falls can complicate and worsen the primary cause of hospitalisation. The emphasis on prevention is the key, and the solutions are simple.
of the event may be debatable, systems issues and service improvements can still be identified.
Case 4: A Fall
What happened A man in his late 60’s fell at home hitting the back of his head. He was admitted to a medium size regional health service for observation of the suspected head injury and investigation of the reason for his fall. He had a variety of medical problems including history of falls, hypertension, osteoporosis, benign prostatic hypertrophy, hiatus hernia and mild obsessive compulsive disorder. The CT scan showed a haematoma and possible venous sinus thrombosis. The next day this gentleman was provided TED stockings (for preventing blood clots) and the nursing assessment identified that he required assistance to shower and attend the toilet. He was able to mobilise independently with a 4 wheel walker. The nurse documented that his risk of falling was high. The physiotherapist reviewed this man, and developed a plan of care. Another CT scan was undertaken and there was no evidence of any extension of the injury with the additional notation that the blood collection was subdural rather than extradural. He was transferred to the Rehabilitation ward for review of reason for falls and ongoing care. He underwent cardiac investigations at a private facility. He is reported as not sleeping well overnight, going to the toilet every few hours. On the fourth day of admission, nursing staff heard a crash in the ward. They found this gentleman on the floor beside his bed. It appeared that he had tried to mobilise to the toilet using his wheelie walker while he had his TED stockings in place. This gentleman deteriorated and became non‐responsive to painful stimuli. Following consultation with the tertiary facility, he was transferred for ongoing treatment. Later that day, a craniotomy was performed and the blood clot removed. Over the next few days, this gentleman’s condition improved and after 2 weeks was transferred back to the regional facility for rehabilitation. He received intensive physio and occupational therapy. He was discharged home 3 weeks after that.
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Analysis (RCA) Commodes are not routinely used at night beside patient beds. This is an issue
because patients with urinary or faecal incontinence or urgency and at high risk of falls may mobilise unsupervised increasing their risk of a fall.
The use of TED stockings increases the risk of falls in all patients who do not wear appropriate footwear over the stockings when they get out of bed.
The RCA team considered the use of non‐slip socks, but when they consulted PSC, were advised that appropriate footwear (velcro or laced well‐fitting shoes) is recommended by current research rather than non‐slip socks.
Recommendations 1. Review the current practice of not placing commodes at the bedside of
patients who are at high risk of falling and who can mobilise with the assistance of walking aids
2. Appropriate footwear is to be used over TED stockings for all patients who have the potential to mobilise independently or with walking aids and who have a high risk of falling.
Discussion Improving safety does not always need high technological solutions. Simply looking at what happened and to then challenge existing practice, clinicians can and do positively influence their environment. In this situation, a simple decision to encourage the use of commodes at the bedside overnight and ensuring use of appropriate footwear will make it safer for all concerned.
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Consumer Commentary:
Sometimes consumers experience ‘near misses’ which can be frightening or annoying. These include nearly going to an operating theatre for the wrong operation, or almost being given the wrong medication. When the staff is able to stop these things from happening because they are being careful to double check, it reinforces the confidence we have in them. Near‐mistakes are a good chance for service‐providers to learn and develop better ways of doing things so that consumers are safer.
No Harm events – why we report them, and why we sometimes analyse them. 44,353 incidents (78% of the total) were reported where there was no harm to patients. We actively encourage our staff to report such incidents because they are our opportunities to learn. Some (but not all of these) are “near hits” – that is, a near‐event, averted at the last minute because of staff vigilance. It is imperative that we analyse these and prevent a recurrence, so that future patients are not exposed to the same risk. The best example of this is, for example, if a patient is in the operating theatre before a mix‐up of patient identity is discovered. Our normal processes should prevent the wrong patient getting anywhere near the operating theatre. If the wrong patient actually gets to theatre, something fundamental has gone wrong somewhere in the system safeguards that precede the bringing of the patient to theatre. Analysis of such “near hits” teaches us a great deal about our healthcare system, so we encourage staff to report incidents even where the patient is not harmed.
Ensuring that lessons are shared and applied With so much reporting, and the resource committed to analysis, it is timely for us to consider how we gain maximum benefit from the lessons learned in incident management. It makes no sense that incidents must occur in multiple sites before there is learning at multiple sites. Sharing lessons learned has the potential to minimise patient harm caused by healthcare. Patient Safety Centre has commissioned the Lessons Learned Project to identify and consult with stakeholders to enhance organisational learning from current patient safety data sources. This work aims to gain insight into the additional patient safety information needs and wants of Queensland Health front line clinicians and managers as well as key external stakeholders such as the Queensland Ambulance Service, the HQCC, general practitioners and the State Coroner.
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Consumer Commentary:
Athough quantifying something like safety is difficult, and is more about the absence of harm, consumers have a role in the evaluation. The more investment consumers have in the process of safety issues, the greater our understanding and the more positive our contribution.
The challenges of measuring “safety” We have stressed that this report does not measure “safety performance” – that is, the number of voluntary incident reports is not a measure of safety, other than through the link between a positive patient safety culture and growth in incident reports. This leaves an untenable situation, where we are presenting data that quite objectively, looks like the system is getting worse, but we are exhorting readers to accept our assertion that, paradoxically, the increase in reported incidents means the system is getting safer. We do not have an Australian dataset that is agreed as measuring safety. This work is occupying health service providers all over the world. There is early work being done in Victoria on a set of indicators drawn from hospital coding data, which measures occurrence of discrete events such as complications of anaesthesia or in‐hospital fracture[11]. Some other jurisdictions have progressed this further. The Victorian work is closely modelled on a model from the USA[12], and in April 2009 the European Network for Patient Safety published a recommended indicator set, whilst acknowledging that these require further testing and validation [13]. The complexity of this field is apparent when one considers that the European group have explicitly excluded some of the indicators included by the Victorian group – there simply is no national or international consensus on how best to measure patient safety. Furthermore, there are variations proposed between institution‐level indicators and system‐level indicators – as evidenced by the variation of each of the above three proposed models from the OECD set of safety indicators, released in 2004.[14] None of the indicator sets pay heed to patient experience‐ that is to say, none of them have implemented the second “major change” proposed by Lucian Leape – to make our systems patient centric. Patient Safety Centre is committed to the development and implementation of a suite of patient safety indicators that can be reliably used to measure safety performance. We are contributing to national debate on this issue, and interested readers are directed to a recent peer‐reviewed paper co‐authored by PSC on the issue[15].
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Consumer Commentary:
Falls complicate the health of many patients, and can be prevented easily in many cases. Consumers feel safer with staff vigilance and strategies to prevent unnecessary falls: e.g. a plan for assistance with mobilising and toileting as needed.
Focus on high risk areas Falls and Pressure ulcers together account for almost 50% of the harm caused to patients by clinical incidents. Suspected suicides account for over 20% of reported deaths. This section provides detailed analysis of the data we have on these types of incidents, and information about the programs we have to reduce preventable harm.
Falls Injury Falls are the single largest reason for an injury related admission to hospital and presentation to the emergency department in people over 65 years of age[16]. Along with cognitive impairment and incontinence, falls are one of the major factors in precipitating admission to residential aged care facilities [17]. Older people entering hospital are particularly at risk of falls. The impact of illness, unfamiliar environment, medications, mobility, hearing and visual problems, all contribute to this risk. Implementation of targeted prevention strategies can produce a reduction in falls injury in acute hospitals and residential aged care facilities [18].
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Fall Primary Incidents Staff reported 11,648 fall primary incidents in 2007/2008, a 6.4% increase compared to 10,950 in 2007. The severity of the incidents reported in 2007/2008 was recorded as:
Figure 23: SAC classifications of reported Falls
SAC 1 6
0.05%
SAC 2 3112.67%
SAC 3 11,33197.28%
By definition, falls resulting in death or permanent harm not reasonably expected as an outcome of healthcare should be reported in PRIME‐CI under the primary incident type of “Sentinel Event” with a SAC rating of SAC 1. The SAC 1 fall primary incidents identified above have been reported in PRIME‐CI with a fall primary incident type and may not be representative of all deaths or permanent harm resulting from a fall.
Falls resulting in injury to the patient Of the 11,648 fall incidents reported, 36% (n=4,289) resulted in injury to the patient. Staff may report one or more injury types for each fall incident. The SAC rating applies only once to the overall fall incident. Where multiple injuries are reported for an incident, the severity of individual injuries cannot be determined. The site of the injury is not collected in PRIME‐CI. In 2007/2008, the top three types of reported injuries resulting from falls were 1. skin tear / cut / laceration, 2. bruise / haematoma / contusion and 3. abrasion / graze.
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Figure 24: Top 5 Injuries resulting from falls
Injury Type No.
reported
Skin Tear / cut / laceration 2423
Bruise / haematoma / contusion
1104
Abrasion / Graze 960
Head injury 323
Sprain / strain 122
Fracture 107
Falls Risk Assessment Staff identified that a Falls Risk Assessment was conducted at admission in 84% of fall incidents (9,753 incidents). Where a falls risk assessment was performed at admission, 78% of patients who were reported as experiencing a fall were rated as a High Falls risk (7,628 incidents). These findings are consistent irrespective of whether the consequence to the patient was harm or no harm. Local ward level analysis is required to determine whether interventions were put in place for patients as a result of being identified as a high falls risk and the effectiveness of those interventions that were implemented.
Figure 25: Types of reported falls
Fall Type No.
reported
Overbalance 3216
Patient unable to recollect 3049
Slip 2556
Legs gave way 1636
Trip 565
Dizziness 350
Faint 308
Unknown 1 Total 11648
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Figure 26: Place where fall occurred
Place of Fall No. Reported
Bed / Bedroom / Bedside 6356
Bathroom / Shower Area 1574
Other 782
Toilet Area 742
Corridor 734
Outdoors 462
Dining / Kitchen Area 459
Patient Lounge Area 408
Gym / Pool / Play / Therapy / Activity Room
73
Reception / Waiting Area 30
Medical Imaging 15
Hospital Entry 13
Total 11648
Figure 27: Function or task being undertaken at time of falling
Function at Time of Fall 2007/2008
Not Stated 2717
Toileting 3133
Patient unable to recollect 2401
Resting 1360
Exercising 895
Bathing/ showering 512
Grooming or dressing 473
Use entertainment 224
Total 11648
Figure 28: Top 5 Patient Related Contributing Factors 2007/2008
Factors which Contributed to Fall Incidents Contributing Factors
% Total Factors
Patient Factors ‐ High Falls Risk 5643 21%
Patient Factors ‐ Age 4715 18%
Patient Factors ‐ Physical impairments 3183 12%
Patient Factors ‐ Dementia 2938 11%
Patient Factors ‐ Diagnosis / Prognosis / Co‐morbidities
2101 8%
Total Contributing Factors 26,321
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Queensland Stay On Your Feet ® Queensland Health has adopted a positive, healthy, active ageing approach to falls prevention. With the permission of the Department of Health Western Australia we are now using the registered trademark Stay On Your Feet® as the main message for falls prevention across the health continuum and the state. This new branding was approved in 2007 by the Department of Premier and Cabinet. A number of health service districts have already adopted the new branding. This branding can be viewed at the Queensland Stay On Your Feet® website: http://www.health.qld.gov.au/stayonyourfeet/default.asp
Falls Safety Officers Implementation Pilot An implementation pilot for enhancing Queensland Health’s response to falls prevention in older people: ‘Queensland Stay On Your Feet®‐ in community, hospital and residential aged care facilities’ was conducted over the period February 2008 to January 2009. The purpose of the project was to trial a strategy to support and coordinate evidence based falls prevention across the health continuum. The strategy involved the appointment of two Falls Safety Officers (FSOs) (one for public hospitals and residential aged care facilities and another for the community sector) in each Area Health Service (Northern, Central and Southern). These six Falls Safety Officers commenced on 5 February 2008. Priority health service districts and facilities were identified using population ageing projections and hospital falls morbidity data, including hip fractures. [19]. An external evaluation of this project [20] demonstrated that the project has raised the profile of falls and falls prevention activities for older people. The cross‐continuum approach has been promoted, ensuring that effective strategies are implemented for identifying people at risk at the interface between the community, hospital and residential care facilities and intervening at those junctures. The Falls Safety Officers completed a total of 39 falls planning or education days, with a total of 920 participants attending, from Queensland Health acute sector staff, Queensland Health community staff, Home and Community Care (HACC), Population Health, public and private and Residential Aged Care, State and Local Government and community Non Government Organisations. On average, representatives from 68.3% of Queensland Health facilities attended the education or planning sessions. Momentum has been built for falls prevention in Queensland across the health continuum. The formal evaluation provides evidence for the cross continuum model for implementing a state‐wide falls prevention strategy. The lessons learned and wealth of data from this project will inform the next step, which is to develop and
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implement a comprehensive and well resourced state‐wide falls injury prevention model so that the work that has been done is sustainable [20].
Queensland Falls Injury Prevention Collaborative The Falls Injury Prevention Collaborative (FIPC) was formed in 2006. It has a network of over 730 voluntary health professionals who have a role or primary interest in falls prevention across the health continuum in Queensland (See Terms of Reference at http://www.health.qld.gov.au/stayonyourfeet/documents/33402.pdf). The FIPC provides a forum to plan, discuss, support and disseminate falls injury prevention initiatives, strategies, research and policy across Queensland Health facilities, other healthcare facilities and the wider community. The FIPC currently has seven working groups. 1. Falls Specialist Officers: Two falls specialist officer projects were funded and completed in 2008 at three hospital sites (one at Ipswich Hospital and the other covering both The Prince Charles Hospital and Redcliffe Hospital). Both research projects have been completed and final reports from the research officers have been submitted. The PSC and FIPC will be undertaking a comparative analysis of the Falls Specialist Officer projects and will publish these results by mid 2010. 2. Falls Clinics Funding was made available to the Northside Health Service District in 2007 to establish a Falls Injury Prevention program. The program consisted of a hospital based Falls Clinic and 2 community based falls prevention programs. A final project report has yet to be submitted for analysis and dissemination of learning. 3. Environmental This working group has undertaken two research projects in the last year. The first study investigated the use of non‐slip socks for falls prevention. This study concluded that patients are more likely to slip whilst mobilising in non‐slip socks compared to bare feet. Non‐slip socks are likely to offer minor relative traction benefit over compression stockings in dry conditions. This research is being prepared for publication. This group also recently completed the data collection for low‐low bed research project and is being analysed in preparation for publication. This research aimed to investigate whether a program of providing low‐low beds to hospital wards reduces the rate of falls and fall‐related injury. 4. Data and Reporting This group is working to progress VLADs3 for falls and looking at data linkages where possible to avoid duplication in reports and developing falls indicators.
3 The VLAD methodology was introduced to Queensland Health to aid the monitoring of quality of services provided. It provides an easily understood graphical overview of clinical outcomes over time and plots the cumulative difference between expected and actual outcomes. Selected Private hospitals are also provided with VLADs for certain indicators. The use of VLAD within Queensland Health is governed by the VLAD Implementation Standard. see http://www.health.qld.gov.au/quality/vlad.asp ‐ accessed 29 August 2009
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5. Nutrition and falls This is a new group, formed in 2009. They are exploring ways to create a greater understanding of how nutrition impacts on falling for people aged 65 years and over. 6. Cross Continuum The Cross‐Continuum Working Group promotes and supports a cross‐continuum focus on falls injury prevention and provides opportunities for an integrated collaborative approach across population health, community health, HACC, acute and residential aged care sectors. This group is chaired by the Population Health Branch. In 2007‐2008, the FIPC Cross‐Continuum Working Group developed with the Queensland Stay On Your Feet® Community Good Practice Guidelines. Dr Nancye Peel, UQ was the lead author. These have been widely disseminated, and are being reviewed at a national policy level by the Australian Commission on Safety and Quality in Health Care.
Education and Resource Development A state‐wide satellite broadcast on falls and vision was held in March, 2008. This allowed the collaborative to work in collaboration with the Queensland University of Technology (QUT). QH worked with Dr Joanne Wood, Professor in the School of Optometry at QUT and Mr Alex Black, researcher. This presentation updated over 150 practitioners from across the state on the latest research in vision and ageing and falls related to changes in visual fields and eye disease. In addition this group has supported the development of several new resources in 2008 which were launched at the 2008 Falls Forum (See below).
2008 Falls Forum The FIPC Education and Resource Working Group supported by the Queensland Health Patient Safety Centre held the 3rd Annual Falls Forum on Friday the 1st of August, 2008 at the Education Centre, Royal Brisbane and Women’s Hospital. The forum attracted 277 delegates. Participants came from across the care continuum including physiotherapists, occupational therapists, registered nurses, patient safety officers, managers and academics. The majority of delegates were from Queensland, with a small percentage having travelled from inter‐state. One focus of the 2008 Falls Forum was the launch of the following Queensland Stay On Your Feet® resources.
Queensland Stay On Your Feet® Community Good Practice Guidelines (for those who work with older people)
‘Will I stay active and independent checklist?’ (Highlighting key reasons why a person may be at risk of falling)
How to Stay On Your Feet® checklist (which comprehensively addresses the personal and environmental reasons for people falling and possible solutions)
In addition, Michael Tilse, Director of the Health Promotion Unit, officially launched the Queensland Stay On Your Feet® Community Good Practice Toolkit and website.
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Consumer Commentary:
For a consumer, spending a long time in a hospital is unpleasant, and to acquire another problem as a result can be quite devastating. Ulcers reduce quality of life and take extended periods of time to heal. Prevention is the best strategy, obviously. When there is a lack of consistency in the care of an ulcer, by hospital or residential facility, repeated hospitalisations and extended suffering results. Strategies which prevent and involve early treatment of pressure sores, are very welcome to consumers.
The toolkit provides practitioners with a step by step comprehensive guide to preventing falls. The collection of tools, checklists and evidenced based information will assist with setting up a community falls prevention program.
Pressure Ulcer Prevention
Issues Pressure ulcers are largely preventable with best practice nursing care. Pressure ulcers cause significant pain and suffering to patients, and can result in death. In addition, pressure ulcers cause financial burden to the healthcare system. Research indicates that patients who develop hospital‐acquired pressure ulcers have their length of stay extended by a median of 4.3 days [21], incurring median opportunity costs of $285 million per annum from hospital‐acquired pressure ulcers. [22]
Pressure Ulcer Primary Incidents reported in PRIME‐CI In 2007/2008, staff reported 3,400 pressure ulcer incidents, an increase of 26.5% from the previous year (n=2,608). However, the prevalence audit (see below) demonstrated that only 25% of pressure ulcer incidents were reported in PRIME‐CI and only 27% of Stage 4 pressure ulcers were reported in PRIME‐CI. This confirms that pressure ulcers remain under‐reported, in spite of the growth in reporting. Further results from the audit are presented separately, after the PRIME‐CI data.
Present on Admission Of the 3400 pressure ulcers reported in 2007/2008, 51% (n=1,731) were not present on admission.
Pressure Ulcer Stage Figure 29 shows the stage of the reported pressure ulcers that were not present on admission in 2008. Three percent (3%) of pressure ulcers (n=63) were reported as Stage 4 and 8% (n=169) reported as Stage 3.
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Figure 29: Stage of Reported Pressure Ulcers that were not present on Admission
Stage 180146%
Stage 272942%
Stage 31559%
Stage 4463%
Pressure Ulcer Risk Tools
There are two tools recommended by Queensland Health facilities to assess the risk of patients developing a pressure ulcer. These are Braden‐Q used for children and the Waterlow Score used for adults. These tools cannot be compared as they use a different scale of risk ratings. Figure 30 therefore excludes pressure ulcers reported by Children’s Health Services, and The Prince Charles Hospital (which does not use PRIME CI for the reporting of SAC2 and SAC3 clinical incidents). Patients assessed as having a Waterlow Score of 15 or above are considered to be at high risk of developing a pressure ulcer.
Figure 30: Waterlow Score by Pressure Ulcer Stage for Pressure Ulcers not present on Admission
Pressure Ulcers Not Present on Admission
Waterlow Score Pressure Ulcer Stage
< 10 10 to 14
>= 15
Total % of Total
Stage 1 48 69 684 801 46%
Stage 2 36 61 632 729 42%
Stage 3 5 9 141 155 9%
Stage 4 2 2 42 46 3%
Total 91 141 1499 1731 100%
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Figure 31: Top 5 factors contributing to Pressure Ulcers
Top 10 Contributing Factors Contributing Factors
% Total Factors
Patient Factors ‐ High Risk Waterlow Score > 10 2194 23%
Patient Factors ‐ Age 1523 16%
Patient Factors ‐ Physical impairments 1452 15%
Patient Factors ‐ Diagnosis / Prognosis / Co morbidities 1185 12%
Patient Factors ‐ Malnutrition 633 6%
Total 9620
As noted above, only 27% of pressure ulcers are actually reported in PRIME CI, so reliance on PRIME CI data does not provide sufficient clarity of the depth and scope of this issue. Recognising this fact, in 2008 the Patient Safety Centre undertook a state‐wide pressure ulcer prevalence audit to provide a snapshot of the total number and severity of pressure ulcers in Queensland Health hospitals and residential care facilities and to measure compliance with key prevention and management activities such as risk assessment on admission, documentation of pressure ulcer management and availability of pressure reducing/relieving devices. The methodology was based on the methodology of WoundsWest, Western Australia. [23]
Results of the Pressure Ulcer Prevalence Audit Three Clinical Nurse Consultants provided oversight to the 2008 pressure ulcer prevalence audit. Data was collected by 457 local auditors, where inter‐rater reliability was maximised through the requirement of all auditors to pass a competency‐based assessment prior to data collection. Malnutrition data was collected at 40 facilities using a validated tool. Across the state, 6371 patients were audited in 137 hospitals and residential care facilities. (See Figure 32)
Figure 32: State‐wide pressure ulcer prevalence audit statistics
Total patients approached
Patients consented for skin inspection
Patients with 1 or more pressure ulcers
95% confidence interval of prevalence
7248 6371 (88%) 970 (15.2%) 14.4 ‐16.1%
The state‐wide prevalence of pressure ulcers was 15.2%. Pressure ulcer prevalence found in Queensland using similar methodology was 18.4% in 2003. This 17% reduction in prevalence in Queensland represents a reduction of 20 000 patients per
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year requiring expensive and painful treatment of pressure ulcers in Queensland Health facilities.4 Best practice pressure ulcer prevention guidelines recommend use of risk assessment tool on admission.[24] The audit found that 70% of patients underwent a risk assessment on admission. The Waterlow risk assessment tool was used on 98% of occasions, in line with the Queensland Health Pressure Ulcer Prevention and Management Guidelines [25]. This demonstrates excellent standardisation of risk assessment across Queensland. The audit identified gaps in documentation, with only 43% of pressure ulcers having current documentation in patient progress notes, nursing care plans, clinical pathways or wound care charts on audit day, or up to four days prior. There is evidence that pressure relieving and reducing mattresses reduce the incidence of pressure ulcers in at‐risk patients compared with standard foam mattresses. [26] Over 95% of approached patients had access to pressure relieving/reducing mattresses. It is evident that the state‐wide mattress replacement program of over 1900 mattresses, which was completed in 2007, was successful. The prevalence of malnutrition was 31%, comprising 27.1% moderate malnutrition and 4.4% severe malnutrition. There was a significant association between the pressure ulcer prevalence and nutritional status (p‐value < 0.0001). Those who were severely malnourished had 4.8 times higher risk of pressure ulcers, compared with patients who were well nourished.
Other achievements Working parties of the multi‐disciplinary Pressure Ulcer Prevention
Collaborative developed additional guidelines for specific groups to be used in conjunction with the updated Pressure Ulcer Prevention and Management Guidelines[27] relating to:
patients with morbid obesity
paediatrics
spinal injury patients and
patients in the community setting. These guidelines are available electronically at
http://www.health.qld.gov.au/patientsafety/webpages/resources.asp Development of a clinician information brochure. Delivery of three satellite broadcasts, two educational DVDs, two educational
forums, and an equipment expo for clinicians5 on pressure ulcer prevention and management across the continuum.
4 Based on admitted patient data 2006-7 http://qheps.health.qld.gov.au/hic/infobank/ACTIVITY/HF/Tables_0607.xls 5 satellite broadcast, forums, & expo presentations are available on DVD. See
http://www.health.qld.gov.au/patientsafety
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Provision of ongoing support to the Pressure Ulcer Prevention Collaborative members – a group of clinicians across Queensland, from public and private sectors, who are passionate about pressure ulcer prevention.
Future work Develop recommendations and targets for pressure ulcer prevention
management in Queensland based on the findings of the 2008 Queensland Health Pressure Ulcer Prevalence Audit via consultation with key clinicians and stakeholders, supported by the Patient Safety Centre.
Partner with clinical services where there is significantly higher pressure ulcer prevalence to develop sustainable strategies to prevent and manage pressure ulcers.
Develop, implement and facilitate of the on‐line learning packages on pressure ulcer prevention and management on the Clinician Development Education Service.
Promote the new evidence based International Guidelines for Pressure Ulcer Prevention and Treatment: Public Policy and Clinical Practice being developed by the National Pressure Ulcer Advisory Panel and the Australian Wound Management Association guidelines, which are due for release in 2010.
Pressure Relieving and Reducing Devices
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Consumer Commentary:
Mental health consumers have often felt like second‐class patients, with less consistent clinical processes, often‐unsafe environments and less formal communication and information strategies. With the addressing of many of these issues in the Achieving Balance report, the experience of mental illness is made less dangerous. Not only will there be a reduction in suicide and self‐harm, but the patient population will suffer less and feel more involved in their safety and general treatment. The improvement in strategies will also result in staff including patients more as partners in their own treatment. Communication will be more open and thus engender more trust.
Mental Health During this period, the Patient Safety Centre Mental Health Program completed a number of initiatives:
Achieving Balance: The Report of the Queensland Review of Fatal Mental Health Sentinel Events, "Achieving Balance", A review of systemic issues within Queensland Mental Health Services 2002 – 2003 [28], concluded on 30 June 2008. Recommendations within the report aimed to address systemic factors identified in the review to reduce the occurrence of fatal mental health Sentinel Events and improve the safety of mental health care. The implementation of nine key recommendations formed the heart of, and drove the initiative. Patient Safety Centre hosted the secretariat and some projects specifically. Other projects were managed by different Queensland Health services such as: the Mental Health Branch; Area and District Health Services; and the Divisions of General Practice and Emergency Medicine. The secretariat was responsible for overarching project management, including coordination of update and progress report information. The following is a brief description of the main areas of impact for the strategies implemented by the Achieving Balance project teams:
Safe clinical processes: Development of a standardised suite of clinical
documentation; processes for mental health assessment, risk assessment and treatment and
Visual observation guidelines.
Management of Dual Diagnosis: Dual Diagnosis policy Dual Diagnosis clinical guidelines Service mapping for mental health and Alcohol, Tobacco and
Other Drugs Services (ATODS) District integration strategy Clarification of roles of Dual Diagnosis Coordinators District level partnerships Increase knowledge and skills in screening and assessment in
Dual Diagnosis and education and resources.
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Safe environments: Building Guidelines Workshops Review of safety of fixtures and fittings Structural corrections Ligature risk auditing Management of plastic bags in mental health units and Searches guidelines.
Administration of Mental Health Act: Limited Community Treatment Review Committees Management of Forensic Order patients including Special Notification
Forensic Patients Management of non‐compliance with Limited Community Treatment Processes for appointment of Authorised Mental Health Practitioners and
Authorised Doctors Involuntary Patient Summary and Victim support services.
Communication and information management: Development of the state‐wide Consumer Integrated Mental Health
Application (CIMHA) (integrating three separate systems) and The incorporation of the standardised suite of clinical documentation.
Emergency departments: Training for emergency department staff The Emergency Triage Education Kit and Emergency Department Mental Health Protocols.
Staffing and bed resources: New, upgraded or redeveloped acute and extended care inpatient services Mental health capital works – seventeen (17) projects Increased support services and packages; increased community
accommodation Transitional supported accommodation Increased mental health workforce International recruitment drive and Case managers to support new recruits.
Support to general practitioners: General practitioner liaison positions Partners in Mind Better Outcomes in Mental Health Care Better Access to Mental Health Care Mental Health Nurse Incentive Program and Communication related to general practitioners incorporated into
standardised suite of clinical documentation.
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Education and training: Queensland Health Clinician Development Program Mental Status Assessment; Risk assessment and risk management Aggressive Behaviour Management Mental Health Act 2000 and Training to Queensland Police Service and Queensland Ambulance Service.
Response to sentinel events: Mental Health Patient Safety Officer Positions Mental Health Adverse Events Register Queensland Health Clinical Incident Management Implementation Standard Standardised state‐wide approach to the management of the suspected
suicide of consumers from community mental health services Mental Health Mortality Review Committees and The Open Disclosure Standard.
Work in progress Patient Safety Centre continues to progress the implementation of a standardised suite of clinical documentation. To date, all Queensland Health Adult Mental Health Services (inpatient and community), Child and Youth Community Mental Health Services and Older Persons Mental Health Services have adopted the standardised suite of clinical documentation. Recent audits have indicated that the service utilisation of these documents across the state is high. Development of standardised suites of clinical documentation for subspecialty services such as extended treatment and forensic services (for both adult and child and youth) will occur in 2009/2010.
Mental Health Safety Data At present, Queensland Health collects and records mental health patient safety data through the following channels. PRIME –CI Reportable Events Briefs and the Reportable Events Register Root Cause Analysis and other clinical incident analysis data Clinical Collaboratives Mental Health Mortality Report Forms and data base; Accreditation and Audit.
External sources of Queensland mental health patient safety data include but are not limited to: information generated from Coronial investigations and research conducted by the Australian Institute of Suicide Research and
Prevention.
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The primary uses for this information are to develop and implement strategies to promote patient safety, prevent patient harm and to monitor the safety of services provided.
Incident Analysis A detailed review of mental health SAC 1 incident analysis during the 2008 calendar year (outside the reporting period for this report) was completed in early 2009. That review is included as Appendix 3. Although the reporting periods do not match, the themes and findings are likely to be applicable to the current reporting period.
The Future: Mental Health Patient Safety Plan
Patient Safety Centre and Mental Health Branch, through the State‐wide Mental Health Network, drafted a Queensland Health Mental Health Patient Safety Plan. This development of this plan meets the commitment outlined in the Queensland Plan for Mental Health 2007 – 2017. The priority areas are: The reduction of suicide and self harm. The reduction of aggressive behaviour in mental health settings, and the
minimisation of the use of seclusion and restraint: These are linked objectives. The prevention of aggression, and the use of calming strategies are linked to a reduction in the need for seclusion and restraint.
Best practice use of medication: An increase in the use of evidence based prescribing, so that treatment is as effective as possible.
Safe transport: In this priority two areas have been grouped for inclusion under the transport priority theme. First is the safe transfer of patients to hospital when they need specialist care. Second is the assessment of fitness to drive, based on risk assessment determined by the effects of illness or prescribed medication on a person’s driving ability.
Cultural safety of Aboriginal and Torres Strait Islander peoples: Respect and safety are inextricably linked. Accurate diagnosis and treatment can only occur in a setting of cultural knowledge and safety.
Safety of mental health services for consumers, carers and families: The acceptability and safety of care services can influence decisions to seek care, as well as the extent of consumer recovery if care is acceptable and delivered in a healing environment. Family safety is also considered, and in particular how services can assist and support consumers who have a parenting role.
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Other Patient Safety Programs
Haemovigilance: Queensland Incidents In Transfusion
Issue The Queensland incidents in transfusion (QiiT) haemovigilance system is being implemented in Queensland in public and private healthcare facilities to allow the assessment of blood transfusion safety across the state. The rationale for QiiT was described in last year's report. Although issues such as patient misidentification, a lack of awareness of the transfusion associated complications and the inappropriate investigation of transfusion reactions continue to contribute to adverse events associated with transfusion, there has been no systematic approach to collecting or analysing these events. As each hospital only rarely experiences a transfusion related sentinel event (ABO haemolytic transfusion reaction) it has been difficult to reinforce or systematically develop aspects of transfusion safety. Therefore, there is a need to collate and utilise the information from across the state to inform appropriate safety measures in blood transfusion.
Achievements The implementation of QiiT has been endorsed by Queensland Health.
All 13 Health Service Districts approached have agreed to participate and 51 hospitals in Queensland are participating in the QiiT haemovigilance system.
Quarterly QiiT newsletters are now distributed to all Queensland Health facilities and staff to provide information on important issues related to blood transfusion safety and to provide feedback and lessons learnt from events reported to QiiT.
QBMP have ensured the Bloodsafe e‐learning package is available to all Queensland Health staff through QHEPS. Bloodsafe e‐learning is a national training package for all levels of staff and covers all important areas of blood transfusion practice.
QBMP staff represent Queensland Health on the National Haemovigilance Advisory Committee.
Future work Implementation of QiiT is the first step towards a systematic approach to blood transfusion safety within Queensland, and encapsulates Queensland Health’s contribution to the future National Haemovigilance Program. The first annual report from QiiT is to be published in 2010. In this report the Haemovigilance Committee and Queensland Blood Board will put forward recommendations on blood transfusion practice based on the analysis of the reports received by QiiT. An important aspect to implementing improvements in blood transfusion safety will be the networking of key personnel across the healthcare services in order to best
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Consumer Commentary:
The clinical handover is one of the most crucial points of communication in the patient experience. There is a long history of the patient being external to this process, and gaps in information as a result. The initiative of bedside handover is a very valuable one for consumers, in that it involves them directly, and provides firsthand information to staff.
utilise available resources. Existing resources such as hospital transfusion committees and transfusion nurse practitioners, or the equivalent safety and quality committees and staff, will be important for the local implementation of recommendations and participation in a state wide network.
Clinical Handover
Issue: Clinical Handover has been defined as: “the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis” [29]. Both information sharing and transfer of responsibility and accountability between healthcare providers are necessary in order to ensure continuity of safe, high quality patient care. Communication failure can account for up to 75% of root causes of adverse events in health care [30]. Ineffective handover can lead to wrong treatment, delays in medical diagnosis, life threatening adverse events, patient complaints, increased healthcare expenditure, increased hospital length of stay and a range of other effects that impact on the health system [31]
Achievements In 2006‐2007 Queensland Health Patient Safety Centre funded the Clinical Handover Pilot Program with the aim of informing development and implementation of a state‐wide Clinical Handover strategy for Queensland Health. It brought together clinicians interested in improving the effectiveness of Clinical Handover and involved implementation of evidence‐based interventions at individual, team and systems levels. The results of these pilot projects were summarised in a final report [32]. Evaluation of the final report has informed ongoing work being done in Clinical Handover. A comprehensive state‐wide Clinical Handover strategy for Queensland Health has recently been completed.
Future work Following endorsement of the 3 year Clinical Handover strategy planning for state‐wide implementation of the final endorsed strategy for Clinical Handover has commenced.
The Clinician Performance Team The Clinician Performance Team is responsible for supporting the activities of the Clinician Performance Support Service (CliPSS), and for providing additional advice and support to districts to assist in management of cases that are not suitable for referral into CliPSS.
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Clinician Performance Support Service
Issue
The Clinician Performance Support Service (CliPSS) was established in September 2008 to provide a fair and effective method of assessing and managing the performance of doctors. It was specifically designed to help districts deal with significant concerns about clinician performance that have proved difficult to resolve by local means alone. Before CliPSS was established, the districts options to assess serious performance concerns were somewhat limited to invoking a formal disciplinary investigation. While this approach was effective in substantiating concerns raised about a clinician, it was considered ineffective to assess and manage performance. CliPSS provides a non disciplinary, non adversarial method of assessing clinician performance using holistic assessment and performance support processes. The CliPSS process is voluntary and is conducted in a collaborative manner using structured assessment methods and individualised performance support plans. The process assesses the practitioner's health as the first step, ensuring detection and treatment of any health issues that could compromise clinical performance and patient safety. The practitioner then undergoes an assessment of clinical performance which is conducted by trained peer assessors from relevant specialist colleges, who review on‐the‐ job performance of normal daily tasks. Overall, CliPSS focuses on enhancing patient safety by supporting and improving professional performance in a supportive environment. The CliPSS assessment process is a forward‐looking risk management and remediation tool, which identifies and fixes performance problems that impact on patient safety.
Achievements The Clinician Performance Support Service was gazetted pursuant to the s31
of the Health Services Act 1991 as a Quality Assurance Committee in September 2008. This confers qualified privilege and confidentiality obligations.
CliPSS has trained 50 Assessors, whose appointment to the role has been cleared by the Medical Board of Queensland, Australian Medical Association and their relevant medical college.
Districts now have an alternative pathway to manage clinician performance matters where there are no concerns about potentially ‘blameworthy acts’, unsatisfactory professional conduct or likely ‘impairment’ as defined in the Health Practitioners (Professional Standards) Act 1999.
CliPSS Quality Assurance Committee has served to enhance patient safety by ensuring that where performance or impairment issues are identified that
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To date, approximately 50 matters have been initially referred to CliPSS for advice or assistance. Of the 50 cases, 44 were either referred to more appropriate services, or were resolved locally following receipt of the CliPSS advice. A further 6 cases were at the level where more formal CliPSS involvement was needed.
CliPSS has provided rapid review of concerns to assist district decision‐making in a further 7 cases. Rapid review involves a records‐based review conducted by one of the CliPSS assessors, with a written opinion provided back to the district.
Future work CliPSS is confined to managing clinical performance concerns about Queensland Health senior doctors who are practising in independent roles and have general registration. The Patient Safety Centre is developing an alternate service outside the CliPSS Quality Assurance Committee, to assess cases where open reporting about performance is more appropriate (for example, for a doctor registered pursuant to s135 of the Medical Practitioners Registration Act 2001, whose registration requires reporting of performance concerns to the Medical Board). A Local Performance Review process is being developed to provide districts with advice, support and tools to undertake their own performance assessments. In addition, the Clinician Performance Team will assess the demand to broaden the scope to include other clinical professions such as nursing and allied health.
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Coronial Management The coronial system has a key role to play in patient safety. Queensland Health staff have an obligation to report deaths to the coroner in accordance with the Coroners Act 2003. Some of these deaths investigated by the Coroner will lead to an inquest which aims to uncover all circumstances of the death and often results in recommendations designed to reduce the likelihood of similar deaths occurring in the future.
Issues: 1. Lack of standardisation in the way deaths are managed at a District level. 2. Coroners Act amendments will impact on current publications and training.
Achievements: 1. Development of an E‐Learning Program to assist Junior Doctors in making competent decisions after the death of a patient. 2. Coordination of activity to ensure Queensland Health provides responses to all relevant coronial recommendations, not only to the State Coroner, but also to the Department of Justice and Attorney‐General for public reporting. 3. Participation in an operational review of the Coroners Act 2003, recently passed into legislation. 4. Development of a joint Process Improvement Action Plan between Queensland Health and the Office of the State Coroner for improving the coronial system for health‐related deaths.
Future Work: 1. Work has begun on the standardisation of processes across the State for the management of deceased patients, ensuring that all forms, procedure documents, flowcharts, etc, are uniform. 2. Further exploration regarding options for sharing lessons learned from coronial investigations, including non‐inquest findings.
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Ensuring Correct Patient, Correct Site and Side, Correct Procedure (3Cs)
Issues The issues around wrong site/wrong patient/wrong procedure are set out in detail in the analysis of the 2007/2008 year. The following section outlines our response to those issues.
Achievements (2005 to 2008) To date, Queensland Health has taken the following actions to address the problem of patient harm associated with procedures involving wrong patient or body part: In 2005 introduced the Ensuring Intended Surgery (EIS) Policy and four‐step
protocol as a mandatory standard for all Queensland Health facilities where surgery is performed.
In 2006 and 2007 conducted state‐wide EIS observational compliance audits
focusing on Marking and the Final Check
44% overall compliance (2006)
56% overall compliance (2007) In 2008 commissioned a major review of the Ensuring Intended Surgery
Policy. This was in response to less than satisfactory levels of observed compliance with the four‐step protocol and in response to incident data indicating that incidents of procedures involving wrong patient or body part continue to occur in operating theatres and perhaps more commonly in other clinical settings (e.g. Oral Health, Radiology).
In 2008 commenced pilot projects expanding the four‐step protocol to
Queensland Health Oral Health and Radiology services. To date, the four‐step protocol has been expanded to:
22 large Queensland Health Medical Imaging Departments (includes general X‐ray, Ultrasound, CT, MRI and Interventional Radiology)
5 major Health Service Districts Oral Health Services (includes Metro North, Metro South, Gold Coast, Sunshine Coast and Townsville).
EIS vs. 3Cs The Ensuring Intended Surgery (EIS) policy review has resulted in a revised policy and supporting implementation standard called the Ensuring Correct Patient, Correct Site and Side, Correct Procedure (3Cs). The 3Cs was approved by the Queensland Health Executive Management Team on 1st June, 2009 as a mandatory standard for all invasive procedures performed in Queensland Health facilities.
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There are 10 major differences between the EIS Policy and the 3Cs Policy and supporting Implementation Standard, including
1. a revised title 2. an enhanced four‐step protocol 3. an expanded scope to include all invasive procedures and 4. greater clarity around roles and responsibilities for compliance and
implementation.
Future work The future work of Queensland Health will include: Enhance implementation of 3Cs in Surgery Further expand 3Cs in Oral Health and Radiology Services Expand 3Cs into other new areas where invasive procedures are performed
such as Nuclear Medicine, Radiation Therapy and Cardiac Catheterisation Conduct another state‐wide observational compliance audit Collaborate with the Royal Australasian College of Surgeons to implement the
WHO surgical safety checklist
Infection Surveillance and Prevention
Issue Healthcare related infections continue to be a source of patient harm worldwide. Queensland Health has a comprehensive state‐wide infection prevention and control program coordinated by the Centre for Healthcare Related Infection Surveillance and Prevention (CHRISP).
Infection Prevention and Control This includes: Infection Control Guidelines Hand hygiene program ‐ Clean hands are life savers Infection Control Management Plans (ICMP) for all healthcare services I‐Care Program to prevent intravascular device‐related bloodstream infections Healthcare associated infection (HAI) surveillance programs for small hospitals ‐
Signal Infection Surveillance, and medium to large hospitals ‐ eICAT system. Staff Protect ‐ protecting staff and patients through immunisation Recommended Practices:
Hollow‐bore Needle Safety Program
Prevention and Control of Infections in Dialysis Settings
Achievements Since the last report, significant achievements have been attained in the Hand Hygiene Program.
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Queensland Health Hand Hygiene Program ‐ Clean hands are life savers In October 2007, CHRISP launched the Queensland Health (QH) hand hygiene
program ‐ Clean hands are life savers. Core elements of the program include:
Recommended practices including a distinct logo and tag line (see http://www.health.qld.gov.au/chrisp/hand_hygiene/about.asp)
Location of alcohol‐based hand hygiene products (alcoholic gel) at the bedside of patients Whilst soap and water are the preferred method for cleaning hands
(through the physical removal of dirt, organic material and microorganisms); alcohol‐based hand hygiene products are able to be located at the point of use, are rapid drying and more effective at killing microorganisms than soap and water (also refer Attachment 1).
Hand hygiene compliance auditing using a standardised tool based on eleven (11) opportunities. All hospitals are currently progressing to collecting data on Pocket
PCs to facilitate timely analysis and reporting of hand hygiene compliance rates locally and at a state level (also refer http://qheps.health.qld.gov.au/chrisp/HH_state_results.htm).
The effectiveness of compliance is being measured through monitoring of methicillin resistant Staphylococcus aureus (MRSA) infection rates (morbidity).
Hand hygiene auditors are currently being validated to ensure intra‐ and inter‐rater reliability.
Hand Hygiene Champions and Life Savers
Visual cues including polo‐shirts and posters
Medical leadership (Voices for Infection Prevention ‐ VIP Program)
Medical industry collaboration with Johnson & Johnson
Engagement of Universities to influence the thought processes of students in relation to hand hygiene,
Partnering Education Queensland and Indigenous Health Services to influence hand hygiene practices of school children and Indigenous people respectively.
Since the introduction of the program, overall hand hygiene compliance by clinical staff has increased more than two‐fold and continues to be well sustained through local ownership by clinicians.
The Informed Consent Program Informed consent is not simply about getting a patient’s signature on the hospital form. It is about the entire interactive communication process for ensuring a patient has the necessary verbal and documented information and advice about the condition, treatment options and material risks associated with any treatment.
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Consumer Commentary:
For a long time, patients have had things done to them, without really knowing or understanding why and how. This has resulted in unnecessary anxiety and a general feeling of exclusion. The better the information and communication, the better the level of trust and co‐operation. Patients respond well to being treated like a partner in their own treatment. Any enhanced communication process must also improve safety.
Each patient is an individual with unique needs, so the informed consent process needs to be individualised according to the patient’s level of understanding and comprehension of what is being discussed. This ensures that appropriate health decisions can be made by the patient.
Queensland Health supports the use of The NHMRC Guidelines for Medical Practitioners [33] and particularly when informing patients on risks associated with medical treatment. This document recommends that health practitioners discuss: the seriousness of the patient’s condition the nature of the intervention, for example, complex
interventions require more information, as do interventions where the patient has no illness
the likelihood of harm and the degree of possible harm. (The greater the risk of harm and the more serious it is likely to be, the more information is needed)
the questions the patients asks the patient’s temperament, attitude and level of
understanding; every patient is entitled to information, but these characteristics may provide guidance to the form it takes and
current accepted medical practice.
Achievements 2007 until present
The suites of cardiac, thoracic and endoscopy consents and corresponding patient information sheets have been revised and updated to meet current surgical practices.
A Blood and Blood Products Consent and corresponding patient information sheet has been developed to assist patients in their decision making.
The state‐wide consent program has been evaluated by an external company. Recommendations to improve patient and staff outcomes are currently being developed in line with the report.
The Informed Consent website has been upgraded and was launched in 2009.
A Strategic Analysis Report for the ‘New Generation of Consent’ has been finalised and options as noted in the report are currently being explored to take consent to a contemporary level. Options include a multimedia strategy to improve patients understanding of proposed medical treatments.
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The informed consent program receives on average per month 7,000 hits to the website home page and 10,500 hits to the forms index page.
Future Work for 2010
Conclude the review of the Informed Consent to Medical Treatment Policy and corresponding Implementation Standard.
Action recommendations from the Evaluation of the State‐Wide Informed Consent Program report.
Complete actioning the approved strategy option/s from the ‘New Generation of Consent’ report.
Medical Fatigue Risk Management Strategy
Issue: Fatigue is a fact of life for doctors. The 24/7 demands on medical staff time resulting from increased complexity of treatments, chronic disease and an ageing population, have been significant. Coupled with a world‐wide shortage of doctors, this has posed a significant challenge for all those in healthcare. The effects of fatigue on performance are well documented. For example, after 14 hours of continuous work, cognitive and motor functions are equivalent to a blood alcohol concentration of 0.05 – above the legal limit for driving a motor vehicle[34]. This has led to both staff and patient harm. Fatigue is a patient safety issue.
Queensland Action – Medical Fatigue Risk Management Strategy The Medical Fatigue Risk Management Strategy (FRMS) is an initiative arising from the Medical Officers (Queensland Health) Certified Agreement (No.1) 2005. Initially targeting hours of work, it has evolved to focus on managing fatigue risk rather than simply work hours. Current actions include: The Queensland Health Medical Fatigue Risk Management – Human
Resources Policy [35] has been endorsed and requires Health Service Districts to have fatigue risk management protocols (including for extreme risks) developed and implemented by 01 January 2010.
Local Fatigue Working Groups are now being implemented in each Health Service District to assist with implementation of the FRMS policy.
A FRMS Resource Pack is now available to support Districts to implement fatigue risk management protocols.
Training for all doctors, medical managers and Fatigue Risk Management Officers is available either through learning workshops or on‐line learning packages.
Management of aggression and other patient behaviours that can lead to harm
Aggression and physical violence in hospitals and health services is a significant
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issue in Australia and worldwide. In an Australian study of incident reports [36], 9% of all reported incidents involved physical violence or violent verbal exchange. This is consistent with the data reported by staff into PRIME‐CI, with aggression incidents accounting for 9% of reported incidents in each of the last three reporting periods. Behavioural incidents and aggression in healthcare facilities can result in harm to patients and also to staff. It is therefore an area where patient safety, and occupational health and safety of our staff overlap. In the 2007/2008 reporting period, the specific category of aggression (n=5037 reports) was the fourth most frequently reported incident, and the more general category of behaviour (n = 4881 reports), was fifth. We also collect information about subcategories of incidents. It should be noted that the total of subcategories exceeds the total of incidents, because if an incident includes, for example, physical and verbal aggression, it will be counted under both sub‐categories. Figure 33 and Figure 34 contain data showing total count of all separate sub‐categories, which exceeds the raw count of incidents, which are reproduced in Figure 35.
Figure 33: Aggression Primary Incident Subcategories
Aggression Primary Incident Sub‐Categories
2007/2008
Aggression – patient to staff – physical 2349
Aggression – patient to staff – verbal 2262
Aggression / Assault – patient to patient – physical 988
Aggression – patient to property 655
Aggression – patient to patient – verbal 543
Aggression – visitor / relative/ other to patient 138
Aggression – patient to visitor / relative / other 119
Other 1
Total 7055
Figure 34: Behaviour Primary Incident Sub‐Categories
Behaviour Primary Incident Sub‐Categories
2007/2008
Risk Taking Behaviour 966
Missing patient / absconded 732
Attempting to abscond 499
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Self harm / mutilation – insignificant 407
Alcohol / drug intoxication / abuse 326
Environmental hazard 285
Sexual – disinhibited / inappropriate behaviour 207
Attempted suicide 206
Self harm / mutilation – significant (requires medical intervention)
172
Discovery of weapons / dangerous items 160
Illicit drug use 113
Theft / loss 57
Setting off fire alarm 40
Sexual ‐ assault 26
Other 1572
Total 5037
As with other incidents, SAC 3 incidents form the majority of those reported.
Figure 35: Severity of Harm resulting from Aggression and Behaviour
Severity Assessment Aggression Incidents
Behaviour Incidents
SAC 1 0 22
SAC 2 41 132
SAC 3 4996 4727
Total 5037 4881
We have also collected information about the factors that were found to have contributed to each of these incidents. As with the incident sub‐categories, the total contributing factors exceeds the total number of incidents because each incident can have more than one contributing factor.
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Figure 36: Top 10 Factors Contributing to Aggression Issues 2007 / 2008
Factors that contributed to Aggression Incidents Factors % Total
Patient Factors – Diagnosis / Prognosis / Co‐morbidities 1503 15.8%
Patient Factors – Responding to psychotic processes 1204 12.7%
Patient Factors – Compliance with treatment / treatment plan
1024 10.8%
Patient Factors – Dementia 801 8.4%
Patient Factors – Age 563 5.9%
Patient Factors – Denied Request 518 5.4%
Patient Factors – Intellectual disability 436 4.6%
Patient Factors – Confusion 387 4.1%
Patient Factors – Physical impairments 292 3.1%
Patient Factors – Alcohol or drug intoxication 279 2.9%
Others 2505 26.3%
Total Reported
9512 100.0%
Figure 37: Top 10 Factors Contributing to Behaviour Issues 2007 / 2008
Factors that contributed to Behavioural Incidents Factors % Total
Patient Factors – Diagnosis / Prognosis / Co‐morbidities 1003 10.5%
Patient Factors – Compliance with treatment / treatment plan
1001 10.5%
Patient Factors – Age 898 9.4%
Patient Factors – Dementia 790 8.3%
Patient Factors – Attempting to abscond 644 6.7%
Patient Factors – Deliberate self inflicted injury 536 5.6%
Patient Factors – Responding to psychotic processes 455 4.8%
Patient Factors – Confusion 375 3.9%
Patient Factors – Physical impairments 355 3.7%
Patient Factors – Alcohol or drug intoxication 327 3.4%
Others 3163 33.1%
Total Reported
9547 100.0%
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The approximately 70% contribution of patient factors in both aggression and behaviour is also consistent with the Benveniste et al study[36], which reported the following findings about reported incidents involving aggression: The commonest locations of the reported incidents was:
emergency departments; and
mental health units. Contributing factors:
Patient‐related – mental health related (40%); dementia (15%); confusion (9%); alcohol or drug intoxication (6%)
Staff‐related – “insufficient staff”; “communication problems”; “inexperienced staff”
System‐related – “security problems”. Queensland Health has taken action in the following ways:
Queensland Health Occupational Health Safety Management System – Occupational Violence Prevention and Management Implementation Standard
Development of an Occupational Violence Risk Assessment Tool to facilitate violence management plans
Occupational Violence Training for staff in relation to the level of exposure to risk and task requirements of differing workplaces
(link) http://qheps.health.qld.gov.au/safety/occup_violence/key_documents.htm
Violence Management Plans relative to assessed risk levels
(link) http://qheps.health.qld.gov.au/safety/occup_violence/key_documents.htm
Improved design of buildings4
In –depth analysis of qualitative incident data to inform future strategies.
Queensland Health’s Occupational Violence Prevention training program (ABM):
Is a nationally recognised competency based training program based on the principles of early intervention, prevention, de‐escalation and avoidance that provides defensible risk under Occupational Health and Safety legislation.
Provides a defence to Queensland Health, Queensland Health employees and the Executive under Occupational Health and Safety legislation. Highlighted by the State Corner findings (COR/03 2193) which recommended “that as a matter of priority all mental health nursing staff and any security officers who may be called on to assist them undertake the aggressive behaviour management course….”
Is benchmarked against other national and international programs and has been subjected to a gap analysis. This analysis has led to further
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improvements in the program.
Is recognised by the Award of the Certificate of Merit from the 2007 Australian Crime and Violence Prevention Awards.
Continuous improvement and refinement of the ABM training program is evident in content review (physical intervention techniques removed or replaced within the program such as removal of the vascular neck restraint and brachial stun); flexibility of content and consistency of delivery by instructor cross district training.
Union and staff support has been obtained for the training program. The implementation is overseen by the OHS Steering Committee and the joint Union/Management Workplace Health and Safety Advisory Committee.
Attendance at differing levels of Occupational Violence Prevention Training for period 2008/2009 – 13,180 employees.
Medication Safety
Medications are the most common form of treatment provided to patients receiving healthcare [37]. In 2008/2009, Queenslanders had over 38 million prescriptions dispensed under the Pharmaceutical Benefits Scheme and the Repatriation Pharmaceutical Benefits Scheme. [38] For the vast majority, medications contribute to well‐being although like all healthcare, there is a risk of harm. Because medications are used so commonly, they are frequently associated with adverse events[39]. Medication‐related problems are a reason why people visit their General Practitioner, attend hospital Emergency Departments or are admitted to hospital and continue to be associated with deaths [40]. Medication incidents associated with adverse reactions and errors can occur anywhere in the chain of supply, distribution, prescribing, dispensing and administration of medication, yet most are preventable[39]. In Queensland Health facilities, in 2007/2008, there were 8,920 medication primary incidents reported. Medication incidents continued to be the second highest type of incident reported across the state behind falls. There was a 18.9% increase in reporting of medication primary incidents compared to 2006/2007 (n=7,503). The impact of these medication incidents can be significant, as demonstrated by the sentinel event data from Figure 6,which showed five deaths related to medication administration errors. Those five incidents were as follows: 2 episodes of haemorrhage from anti‐coagulant medications patient self‐administration of oral medications (opiates) by intravenous route administration of a drug to which a patient had a documented allergy administration of adrenaline in error where infusion was thought to contain
an antibiotic
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Medication Errors In reporting a medication incident in PRIME, each incident may involve one or more errors, resulting from multiple drugs involved in the incident, errors occurring at multiple stages of the medication cycle (e.g. dispensing/administration) or multiple error types occurring (e.g. wrong dose/wrong patient). Staff reported 11,542 medication errors in 2007/2008, compared to 10,522 medication errors the previous year. Medication administration errors were most commonly reported followed by prescribing errors. The attribution of the medication errors stage has improved since 2006/2007 with a reduction in “Not stated” reports.
Figure 38: Stages of medication administration associated with error
Medication Error Stage 2006/2007 2007/2008 % Growth of
Reporting
Administration 5726 6831 19.3%
Prescribing / Ordering 1162 2111 81.7%
Dispensing / supply 1785 1989 11.4%
Monitoring 194 409 110.8%
Transcribing 129 182 41.1%
Not Stated 1526 20 -98.7%
Total Medication Errors 10,522 11,542 9.7%
Medication errors are common but fortunately, these errors are infrequently associated with patient harm. In 2007/2008, 5.8% of medication incidents were reported as causing patient harm. Of the total occasions of harm reported in PRIME in 2007/2008, 4.1% were linked to medication incidents (compared to 7.2% in 2006/2007).
Contributing Factors The PRIME system allows one or more contributing factors to each medication incident to be recorded. Staff reported 12,431 contributing factors, providing a broad picture of the things that can make errors more likely to occur. Staff distraction or inattention was felt to be the most common contributing factor.
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Figure 39: Top 5 Staff / Practitioner Factors Contributing to Medication Incidents 2007/2008
Factors that contributed to Medication Incidents Count % 2007/2008
Staff / Practitioner Factors - Distraction or inattention 2654 21
Staff / Practitioner Factors - Instructions not followed
or misinterpreted
1829 15
Staff / Practitioner Factors - Communication - Care /
Treatment
1375 11
Staff / Practitioner Factors - Knowledge / Skill issues 1184 10
Staff / Practitioner Factors - Workload issues 826 7
Total Contributing Factors 12431
Queensland Health Action: Improving medication safety in Queensland Health involves a partnership between the Health Service Districts and the Safe Medication Management Unit within Medication Services Queensland. Together, a comprehensive range of initiatives and programs has been put into place to tackle unsafe medication practices. A key approach taken is to work with clinicians to develop and implement standardised systems and processes, tools and guidelines for use across all Queensland Health facilities. One effective way of reducing the risk of medication‐related harm is using a standardised medication. A recently published study about the impact of a standard medication chart in some Queensland public hospitals shows that this approach can reduce the rate of prescribing errors on inpatient medication charts [41]. Similarly, standardised forms designed to make to make insulin prescribing, administration and monitoring safer, has improved the management of insulin [42]. The insulin forms are currently used in 86% of QH inpatient beds across the state with the remainder to follow in 2009/2010. Other high risk medications targeted include warfarin and heparin (blood thinning drugs), opiates (for pain control) and intravenous fluids. Current initiatives include:
Raising nurse awareness of medication risk by distributing a scenario‐based training package to Queensland Health sites inpatient facilities – 87% used the scenarios as part of local nurse education and training.
Trialling a version of the National Inpatient Medication Chart that includes a venous thromboembolism risk assessment tool and pre‐printed options for preventive treatment to decrease the incidence of venous thromboembolism.
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Helping clinicians select the right dose for renally excreted medications by implementing web‐based dose calculators to assist clinicians with the calculation of:
Enoxaparin prophylaxis and treatment doses
Aminoglycoside initial and subsequent doses
Reducing the risk inadvertent intravenous bolus of concentrated potassium by introducing 40mmoL in 100mL potassium chloride minibags into all Queensland public hospital intensive care units.
Reducing error in infusing intravenous medications by developing a standardised set of drug‐specific dosing rate profiles for use in intravenous infusion safety software on infusion pumps.
Exploring the practices and documentation Queensland public hospitals have in place for patients receiving cancer chemotherapy in order to identify areas where patient safety could be improved.
Reducing the risk of medication errors associated with poor information about a patient’s medications by introducing the Medication Action Plan form in acute hospitals to improve the communication of information about medications as patients are admitted and discharged from hospitals.
Developing training and competency assessments modules to support rural and remote nurses in taking medication histories, medication reconciliation at discharge and provision of Discharge Medication Records
Providing ongoing training for rural and remote nurses and pharmacists to more effectively use the state‐wide electronic Discharge Medication Record system, eLMS. eLMS medication information is drawn into the Electronic Discharge Summary (EDS) system currently being implemented in Queensland Health by the Information Division.
Undertaking ‘time and motion’ observational audit of discharge pharmacy services at a number of tertiary hospitals to understand how to improve pharmacy services to further reduce the risk of patient medication‐related harm.
Working in partnership with the Mental Health Branch to develop an integrated strategy for medication safety in mental health and to develop and implement solutions to the needs identified by consumers, carers and clinicians.
Developing and updating a tutorial program to educate junior medical practitioners on safe prescribing practices. The program is taught in Queensland university medical school courses.
Working with pharmacists to improve their performance of medication risk‐reducing strategies such as effective medication history taking and identifying and resolving medication‐related problems that may lead to patient harm.
Increasing awareness of telepharmacy services as a means of reducing medication safety risks for rural and remote patients by improving access to the pharmacist services shown to reduce medication risk.
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Consumer Commentary:
Consumers are usually understanding of errors, and, when one occurs, do not often think of retribution or compensation. Historically, there has been a culture of secrecy and avoidance within health services when mistakes are made, and consumers feel ignored or disbelieved. With the initiative of Open Disclosure, consumers will often get what they need from this relatively simple and low‐level process. Most consumers want some combination of apology, explanation, advice, and reassurance of future improvements. Open Disclosure treats consumers with respect, and that means more positive partnerships and less blame.
Open Disclosure Program The Open Disclosure Program is one of the eight initiatives of the Australian Commission on Safety and Quality in Health Care (ACSQHC) endorsed by AHMC in 2008. Open Disclosure is the open discussion of incidents that have resulted in harm to a patient while receiving healthcare. This includes: An expression of regret or apology for the incident A factual explanation of what happened The potential consequences The steps being taken to manage the event and prevent
recurrence. [43] Queensland Health is committed to Open Disclosure and to providing honest and factual responses to patients, families and staff who experience, or are affected by, serious adverse events [44]. This commitment will ensure that patients/families will experience a reliable, caring and effective response from Queensland Health after such an event.
Issues The focus of Open Disclosure is primarily to assist affected patients/families and clinicians with the grief associated with an adverse event. Staff involved in serious adverse events are usually frightened and vulnerable, and these emotions reduce their ability to focus on the needs of the affected patient or family. Formal Open Disclosure is integrated within the Clinical Incident Management Implementation Standard[45] and is mandatory for all SAC 1 incidents. However, data collected by the Patient Safety Centre during 2008 suggests that this is not happening for all affected patients and families. The benefits of the Formal Open Disclosure include: Improved communication between staff and patients and
their families in the event of an adverse outcome Potential for the reduction of anger from patients and their
families and staff Opportunity to identify the root causes of adverse events Ability to learn from the adverse event Renewal of trust and satisfaction in the health system by
patients and health professionals[46]
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Achievements State‐wide implementation of the Open Disclosure Program commenced in February 2007. Open Disclosure in Queensland Health is based on a Communications Consult Model[47]. At the heart of the model is a senior hospital clinician who is specially trained to support Open Disclosure by working with the affected clinician and patient/family. To date, Queensland Health has trained over 300 senior clinicians for the role of Open Disclosure Consultants across the state. ACSQHC surveyed 480 health professionals for the evaluation of the National Open Disclosure Standard pilot with over 46% of responses provided from Queensland. The survey reported that 100% of health professional respondents were of the view that the Open Disclosure process enables patients to have the opportunity to ask questions and 97% of patients are told what steps are being taken to avoid adverse incidents occurring again[46]. Future work is planned to gather information from patients about their experiences in Open Disclosure.
Future Our highest priority for future work is to continue to build on the adherence to Formal Open Disclosure processes for SAC 1 incidents. In addition to this formal, institutional response, Queensland Health recognises that front‐line clinicians are usually involved in initial disclosure discussions with a patient immediately following an adverse event. Clinician Disclosure training for all senior Queensland Health clinicians is currently under development and due for commencement in 2010. This will be followed by dialogue with universities who train clinical staff, to develop appropriate training during the student years. Clinician Disclosure will not replace Formal Open Disclosure for SAC 1 events, but provides a structured, consistent and patient‐centred approach to the very first discussions that occur after an adverse event. Queensland Health is actively participating in the ACSQHC 100 Patient Stories research and is a member of the National Strategic Advisory Panel overseeing the current Open Disclosure work by the commission.
Patient Identification
Issue Throughout the healthcare industry, the failure to correctly identify patients and correlate that information to an intended clinical intervention continues to result in wrong person, wrong site procedures, medication errors, transfusion errors and diagnostic testing errors. A patient identification error is recognised to have occurred if:
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1. The identity of the patient has not been clearly established such as when one patient is mistaken for another, and/or, 2. The nature of the intended care (procedure/treatment) is not clearly established, which may result in the correct care not being applied to the correct patient. That is, a “mismatch” occurs between a given patient and their care (Patient Safety Centre, 2009). This is a recognised international problem that has been identified as a key patient safety goal or program by all of the major international patient safety agencies including the World Health Organization, National Patient Safety Agency in the UK, Joint Commission International Centre for Patient Safety and National Patient Safety Centre in the USA. The Australian Commission on Safety and Quality in Health Care’s Patient Identification Program includes a number of different initiatives that focus on different aspects of this problem; all aim to reduce errors and improve patient identification processes. These include: (1) a national standard for patient identification bands, (2) enhancing the 3C’s protocol, (3) expansion of the 3C’s protocol into other therapeutic areas, (4) improving learning from sentinel events and Root Cause Analyses, and (5) investigation of technological solutions to address the problem of patient misidentification [48]. Queensland Health had 27 reported incidents of procedures involving wrong patient or body part during the 2007/2008 reporting period. Of these, “wrong patient” was the most frequent error type, accounting for 41% (N=11) of reported cases.
Achievements The Queensland Health Patient Safety Centre initiated a State‐wide Patient Identification Project (October 2008 – January 2009). The objective of this project was to develop a Strategy Options Paper to provide a planning framework to promote improved patient identification systems and processes in Queensland Health public hospitals. The Strategy Options Paper[49] was submitted and endorsed by the Queensland Health Patient Safety and Quality Board in May 2009. The Committee endorsed a risk stratified approach to implementation of the 11 key strategies outlined in the Strategy Options Paper.
The Future The Patient Safety Centre will progress 11 recommended key strategies outlined in the Strategy Options Paper, commencing with development of a state‐wide Patient Identification Policy and Implementation Standard, including state‐wide standardisation of patient identification bands.
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Recognition and Management of the Deteriorating Patient
Issue This area of priority work arises from our identification of this as a recurring theme in Root Cause Analysis. When patients in our care begin to deteriorate, it sometimes takes too long to recognise this, and too long to respond appropriately.
Achievements We have conducted a pilot of a specially designed observation chart for Children, called the Children's Early Warning Tool (CEWT). At time of writing, the pilot evaluation is currently being undertaken, and if positive, will result in CEWT being rolled out state‐wide. Patient Safety Centre has also produced a Technical Discussion paper on this issue more generally[50]. The discussion paper has been circulated to stakeholders for feedback.
The Future PSC is working in collaboration with the University of Queensland, Skills Development Centre and the Australian Commission for Safety and Quality in Healthcare to undertake human‐factors research into the design of observation charts, and how staff use them. The results of this research will influence the design of a standardised observation chart state‐wide, and potentially, nationally. The technical discussion paper (and the feedback received about it) will be used to provide recommendations for strategies to improve both the recognition and response to deteriorating patients. We are undertaking a systematic analysis of RCAs to date, with a specific sub‐project working on the area of recognition and management of the deteriorating patient. The results of that project will be available in mid 2010.
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Directions for future work One of the most frequently reported incident categories (9% of total) is "Deviation from Planned Care". This is a diverse grouping of incidents, that captures the majority of occasions where things did not go as planned. Just over 30% of these incidents related to cancellation of scheduled treatment and another 10% related to delay in assessment/treatment.
Figure 40: Deviations from Planned Care: Primary Incident Sub‐Categories
Primary Incident Sub-Categories
2007/2008 % of Reports
Cancellation of procedure / appointment / surgery 1598 30.8% Planned care not performed 817 15.8% Delay in assessment / treatment 561 10.8% Complication / side effect of treatment 521 10.1% Failure to assess and treat effectively 407 7.9% Handover issues 230 4.4% Medical emergency - cardiac / respiratory arrest 106 2.0% Pain management 58 1.1% Misdiagnosis / delayed diagnosis 53 1.0% Unexpected readmission to hospital 40 0.8% Self extubation 26 0.5% Unplanned return to theatre 18 0.3% Coordination of treatment 1 0.0% Other 1679 32.4%
Total 5182 100.0%
Notably, deviations from planned care have a different distribution of SAC rating than the general body of incidents, with almost 13% being either SAC 1 or SAC 2, compared with just over 4% of all incidents being SAC 1 or SAC 2.
Figure 41: Severity of Harm resulting from Deviations from Planned Care
Severity Assessment Code Incidents % Total
SAC 1 31 0.6%
SAC 2 607 12%
SAC 3 4544 87.4%
Total 5182 100%
Just as we identified 3 new priority areas last year (Recognition and Management of the Deteriorating Patient, Clinical Handover and Patient Identification), cancellations and delays to planned treatments appear to be an area requiring further examination. Whilst they may often be unavoidable, strategies to ensure that they do not result in harm are absolutely essential.
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Appendix 1: Procedures Involving the Wrong Patient or Body Part
National context The incident category procedures involving wrong patient or body part is one of eight national, reportable sentinel events. For the past three years (2004 ‐ 2007), procedures involving wrong patient or body part has been the most frequently reported sentinel event category, accounting for up to 62% of all reported Sentinel Events in Australia [39].
Queensland Health During the reporting period, there were 8 sentinel event cases of procedures involving wrong patient or body part reported into PRIME‐CI, and a further 19 that had less serious consequences. During the same reporting period (2007/08), there was a total of 1,400,323 procedures performed in Queensland public hospitals [1] These figures suggest that incidents of procedures involving wrong patient or body part are a relatively rare event in Queensland public hospitals. Even so, Queensland Health recognises that these events can be devastating for patients, their families and staff involved and that patients have a right to the safest possible healthcare. This is why Queensland Health is committed to learning from these events and ensuring appropriate corrective action is undertaken to minimise preventable patient harm.
Description and analysis of 27 cases Figure 42 provides a brief description of the 27 cases of procedures involving the wrong patient or body part reported to the Queensland Health Patient Safety Centre during 2007/08. A detailed description of cases is provided at the end of this section, in Figure 52. As Figure 42 shows, wrong radiology procedures and wrong tooth extractions were the most frequently reported incidents of procedures involving wrong patient or body part accounting for 62% (N=17) of all cases reported during 2007/08.
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Figure 42: Brief description of reported cases
Brief description
No.
Wrong radiology procedure 11
Wrong tooth extraction 6
Wrong site/side surgery of female reproductive organ (ovary, fallopian tube) 3
Wrong tooth restoration/filling 2
Tubal ligation not performed, resulting in unplanned pregnancy 1
Surgical repair of epigastric hernia not performed, lipoma excision performed 1
Wrong surgical incision at base, instead of head, of big toe 1
Wrong patient transfused with blood cross‐matched for another patient (correct blood type)
1
Wrong sided femoral block anaesthetic and subcutaneous tunnel 1
Total 27
Figure 43 provides an overview of the 27 reported cases of procedures involving wrong patient or body part, for 2007/08 by specialty area.
Figure 43: Reported cases by specialty
The three most common specialty areas for reported incidents of procedures involving wrong patient or body part, in order of frequency were Radiology (N=11, 45%); Oral Health (N=8, 30%) and Surgery (N=6, 22%). The 27 cases of procedures involving wrong patient or body part were further classified into one of four categories: wrong patient; wrong site; wrong side and wrong procedure, based on an assessment of the primary error type. It is important
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to note that this categorisation is somewhat arbitrary as a “wrong patient” incident will generally also result in a “wrong procedure” incident. The outcome of this analysis is shown in Figure 44.
Figure 44: Reported cases by primary error type (N=27)
Wrong procedure
4
15%
Wrong patient11
41%
Wrong site6
22%
Wrong side 6
22%
As Figure 44 shows, “wrong patient” was the primary error type, accounting for 41% (N=11) of reported cases. “Wrong site” and “wrong side” were the next most frequent error categories, each accounting for 22% (N=6), or a total of 44% of reported cases.
Extent of patient harm The proportion of cases associated with patient harm or no harm were almost evenly split. Specifically, under half (41%) of the cases involved patient harm (SAC 1 and SAC 2); with the remaining 59% of cases involving no or minimal patient harm (SAC 3). There were no patient deaths in the 8 SAC 1 events ‐ all 8 reported events were classified as SAC 1 because of permanent harm.
Figure 45: Reported cases by SAC (level of harm) (N=27)
SAC18
30%
SAC23
11%
SAC31659%
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Contributory factors Contributory factors are those factors which are directly relevant to the incident [51] and must be understood so that effective corrective actions can be implemented and future incidents of procedures involving wrong patient or body part are minimised or prevented. Our analysis identified a total of 109 contributory factors or four contributory factors on average per reported incident. The five most frequently assigned contributory factors for the 27 reported cases are presented in Figure 46.
Figure 46: Top five contributory factors
Lack of availability or failure to follow policies/procedures was the leading contributory factor, followed by staff factors (e.g. training/knowledge/skills/competence/supervision); staff‐to‐staff and staff‐to‐patient communication; correctness and completeness of documentation and patient factors e.g. age, hearing/cognitive impairment (Figure 5).
Compliance with four-step safety protocol6 During the full 12 months of the reporting period (1 July 2007 to 30 June 2008), the EIS four‐step protocol was a mandatory requirement for all surgical procedures performed in Queensland public hospitals. In the second half of the reporting period (1 January to 30 June 2008), the EIS four‐step protocol was being gradually expanded to include Radiology and Oral Health Services. Figure 47 illustrates the findings of this analysis and highlights a significant lack of application of the four step protocol in these cases. This finding is consistent with Figure 5 which indicated that the leading contributory factor in these reported cases of procedures involving wrong patient or body part (N=27) is a lack of availability or failure to follow policies/procedures.
6 The four-steps include (1) Informed Consent Check (2) Marking/Verification of Site and Side (3) Patient Identification Check and (4) Final Check. Queensland Health Ensuring Intended Surgery Policy/Protocol, 2005-2009 (No. 26961). Also known as Ensuring Correct Patient, Correct Site and Side, Correct Procedure (3Cs).
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More specifically, the analysis revealed that none of the 27 cases sufficiently implemented all of the four‐steps in the protocol and all of the 27 cases failed to apply at least one of the four steps in the protocol. Of particular note, the analysis indicated that none of the 27 cases performed or adequately performed a final check and more than half of the cases (N= 17/27 or 62%) did not perform or adequately perform an informed consent check. A patient identity check and marking or verification of site/side appeared to be lacking in 40% of (N=11/27) reported cases.
Figure 47: Completion of the four step protocol (N = 27)
Comparison with previous reporting period (2006/07 vs. 2007/08) The 27 reported cases of procedures involving wrong patient or body part represents a 18% reduction from the 33 cases reported in the previous reporting period 2006/07
Figure 48: Comparison of numbers reported in 06/07 and 07/08
0
5
10
15
20
25
30
35
2006/2007 2007/2008
Count of reported procedures
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Figure 49: Comparison of reported cases in 06/07 and 08/09 by specialty
There has been a noticeable reduction in the number of incidents reported for specialties of Surgery, Pathology, Anaesthesia and Cannulation. Equally, there has been a noticeable increase in the number of incidents reported for the specialties of Oral Health and Radiology. Specifically, the number of incidents reported for surgery has almost halved from 2006/07 to 2007/08 (down from 11 to 6). On the other hand, the number of reported incidents for Oral Health and Radiology have more than doubled from 2006/07 to 2007/08 (up from 3 to 8 for Oral Health and up from 4 to 11 for Radiology, respectively). The increase in reporting in Oral Health and Radiology may be attributed to greater level of awareness of wrong patient/body part incidents associated with the introduction of the EIS four step protocol in these areas during the latter half of this reporting period.
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Figure 50: Comparison of reported cases in 2006/07 and 2007/08 by primary error type
6
6
11
4
5
8
15
5
0 5 10 15 20
Wrong Side
Wrong Site
Wrong Patient
Wrong Procedure
2006/2007
2007/2008
When the “primary error type” for reported cases of procedures involving the wrong patient or body part were compared for 2006/07 and 2007/08 (Figure 9), a similar pattern emerged. Of particular note, “wrong patient” was the most frequently reported primary error type in both reporting periods, followed by “wrong site” and “wrong side”. When the level of harm for reported cases of procedures involving the wrong patient or body part were compared for 2006/07 and 2007/08 (Figure 9), a slight increase in the proportion of cases associated with patient harm was observed.
Figure 51: Comparison of reported cases in 2006/07 and 2007/08 by harm/no harm
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Figure 52: Details of the 27 Cases of procedures involving wrong patient or body part
Category Description
Anaesthesia Patient received femoral block anaesthetic and subcutaneous tunnel for epidural catheter on LEFT side instead or RIGHT side (of neck of femur)
Pathology Wrong patient transfused with a bag of blood cross‐matched for another patient (same blood type)
Patient (child) received wrong tooth restoration (Tooth 17 filled instead of Tooth 16)
Patient (child) received wrong tooth extraction (Pre‐ molar Tooth 44 extracted instead of Tooth 45)
Wrong patient (child) received tooth filling (Tooth 84 filled unnecessarily) intended for another child
Wrong tooth extraction (Patient presented with RIGHT sided pain, tooth extracted on LEFT side in error after misdiagnosis).
Patient (child) given wrong tooth extraction (Permanent Tooth 31 extracted instead of deciduous Tooth 71). Tooth subsequently reimplanted.
Patient received wrong tooth extraction (Tooth 47 instead of Tooth 48)
Patient (child) received wrong tooth extraction (RIGHT second permanent pre‐molar extracted instead of LEFT first permanent pre‐molar)
Oral Health
Patient received wrong tooth extraction (Tooth 24 removed instead of Tooth 25)
Wrong patient received radiology procedure (ultrasound of the abdomen) intended for another patient
Wrong patient received radiology procedure (Chest X‐ray) intended for another patient
Wrong patient received radiology procedure (CT head, Chest X‐ray and Abdomen X‐ray) intended for another patient
Wrong patient received radiology procedure (CT angiogram of head) intended for another patient
Wrong patient received radiology procedure (Chest X‐ray instead of Jaw X‐ray) intended for another patient
Wrong patient received radiology procedure (abdominal X‐ray) intended for another patient
Wrong patient received radiology procedure (abdominal X‐ray) intended for another patient
Wrong patient (child) received radiology procedure (MRI and CT Scan) intended for another child
Patient received incorrect radiology procedure (AP lumbar spine X‐ray unnecessarily as part of examination of Thoracic spine)
Wrong patient received radiology procedure (X‐ray of Abdomen instead of X‐ray of Chest) intended for another patient
Radiology
Patient received incorrect radiology procedure (repeated X‐ray)
Patient received incorrect surgical incision at circumference (base) of the big toe, instead of incision at head of the big toe
Patient received small lipoma excision, instead of surgical repair of epigastric hernia
Patient consented to LSCS and tubal ligation. Tubal ligation was not performed, resulting in a subsequent unplanned pregnancy
Patient consented to RIGHT sided cystectomy and RIGHT sided oophorectomy (removal of RIGHT ovary), 'if required'. Patient received a RIGHT sided salphingo‐ooporectomy (removal of RIGHT fallopian tube and ovary) and LEFT sided tubal ligation in error.
Patient consented to LEFT oophorectomy (removal of LEFT ovary only). Patient's RIGHT ovary was removed in error before correct LEFT ovary was removed.
Surgery
Patient consented to laparoscopically assisted vaginal hysterectomy and LEFT salpingo‐oophorectomy (removal of LEFT fallopian tube and ovary). Patient's RIGHT fallopian tube and ovary were removed in error.
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Appendix 2: Learning from Adverse Events In 2008, the PSC received notification of 298 SAC 1 events. Of these, (as of 9 February 2009) 93 SAC 1 clinical incident analysis reports had been received by the PSC. Of these 72 were reviewed (and available electronically). The breakdown of the 93 incident analysis report types received is shown in Figure 53.
Figure 53: SAC 1 Reportable Event Brief Analysis Type
Incident Analysis Type Number completed (2008)
Root Cause Analysis 62
HEAPs 23
Clinical Review 8
Total 93
Electronically available for review 72
Final Analysis Findings An analysis of the review findings and recommendations was undertaken of the 72 reports available, to identify emerging themes. Figure 54 highlights the findings of the analysis of incidents reviewed.
Figure 54: Clinical Incident Analysis Findings
Clinical Incident Analysis Findings Number of incidents
% of incidents
Failure to identify the deteriorating patient 14 19 %
Suspected suicide of a consumer of mental health services
11 15 %
Failure to recognise a cardiac event occurring 9 13 %
Death or permanent harm to a neonate, or in‐utero foetal death
8 11 %
Incorrect procedure, intervention or diagnosis 8 11 %
Death following a fall 7 10 %
Procedure involving wrong patient, site or side 4 6 %
Foreign object left in patient post procedure 3 4 %
Miscellaneous Others 8 11%
Total 72 100 %
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The use of the term failure to identify the deteriorating patient includes a failure to monitor vital signs consistently, a failure to recognise that derangements in physiological markers are signalling deterioration in the condition of the patient, or a failure to act or trigger assistance in response to the worsening vital signs. Of the 72 clinical incident analysis reports received and analysed a total of 288 recommendation items were considered. Figure 55 identifies the recommended priority areas under which all of the recommendations could be placed.
Figure 55: Recommendation Themes
Theme
Policies and procedures
Includes development, review, implementation and oversight of: policies, procedures, protocols, workplace instructions, guidelines, clinical pathways, and workplace practice not otherwise specified.
Training and Development
Includes training education, orientation, and supervision.
Clinical Handover
Includes handover, transfer processes, discharge planning and processes, follow up care, and communication among staff / care providers.
Documentation, Including medical records, electronic clinical information systems.
Assessment Includes particular reference to risk assessment and screening.
Competency & Skill Mix
Includes staffing levels, workload, skill mix, rostering, scope of practice, credentialing, fatigue, and team composition.
Medication
Equipment Includes access to, purchase of new, updating and replacement of, new uses for, labelling of, and checking and auditing.
Note: In any given recommendation, several priorities may be referred to and each priority was recorded. For example a recommendation for training staff in a piece of new equipment necessary to support a new procedure contains the priorities of training, equipment and procedure. Figure 56 demonstrates the number and percentage of recommendation themes identified.
Figure 56: Relative Emphasis of the Themes
Theme # of times theme was counted
% of times theme was identified
Policies and procedures 159 36 %
Training & Development 60 14%
Clinical Handover 60 14%
Documentation including medical records, electronic clinical information systems
54 12%
Assessment 37 8%
Competency & Skill mix 37 8%
Equipment 26 6%
Medication 9 2%
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The recommendations are a combination of those directly related to causal statements and those made following lessons learnt (findings observed during the RCA process but not considered to be related to causal statements pertaining to a root cause of the incident). Of the 288 recommendations reviewed, there are 29 identified nursing specific recommendations in total (10%). Nevertheless, the vast majority of recommendations will pertain to or impact upon the practice of nurses. The recommendations may not state which discipline(s) they apply to as this is implied in the context of the recommendation. Of the clinical incident recommendations which identified nursing, there were 71 recommendations where nursing staff were identified as having direct responsibility for implementation / oversight (25%) of the recommendation.
Key priorities identified for each of the categories are listed below.
Failure to identify deteriorating patient Clinical Handover: Communication of the situation of the patient &
standardisation of the process. Observations: assessment and escalation when appropriate. Safe transfer: policy of transfer, communication of risk to transferring body
e.g. Queensland Ambulance Service. Use of Primary Care Manual for evidence base. Medical Emergency Team: Timely communication to the Medical Emergency
Team as well as team work processes within the emergency team. Abnormal Results: Communication and escalation of abnormal results
including documentation.
Suspected suicide of a consumer of mental health Risk Assessment: Implementation of risk assessment, including care planning
of risk assessment and escalation of risk. Standardisation and explicitness of processes, policy and training.
Establishment of mechanisms for follow up and support following discharge. Safe transfer of patients from one service to another. Clinical Handover processes and expectation (including reference to risk: of
harm to self and others) between clinicians and inpatient unit, family and inpatient unit, facility to facility.
Failure to recognise a cardiac event occurring Use of Primary Care Manual to assist smaller facilities to identify cardiac
event occurring. Utilisation of Chest Pain Protocol, including identification and treatment.
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Safe transfer of patient with cardiac event, including communication with clinical coordination team and receiving facility and skilled escort.
Up skill of nursing competencies, including Electrocardiograph (ECG) and nursing observations. i.e. interpreting ECG, escalating concerns from ECG and recognising and escalating concerns from nursing observations.
Death or permanent harm to a neonate, or in‐utero foetal death Obtain quality Cardiotocography (CTG) readings. Interpretation and escalation of concerns regarding observations and CTG
readings. Up skilling of rural nurses in care of women in labour and the neonate. Model of Care – professional / cultural relationships between medicine and
midwifery. Neonatal Emergencies ‐ access to expert advice to prepare neonate for safe
transfer. Standardised handover for neonatal emergency escalation. Access to and instruction on the use of evidence based information. Standardisation of Risk Assessment of mother early in pregnancy and during
labour supported by plan of care. Appropriate escalation for advice re possible transfer and preparation and
care prior to transfer. Establishment of protocols and pathways.
Death following a Fall Standardisation of risk screening and assessment for falls that leads to a plan
of care that is implemented. Adoption and implementation at local level of a falls policy and program that
staff understand and implement.
Incorrect Procedure, Intervention including procedure involving wrong patient, site or side Implementation of the Ensuring Correct Patient, Correct Site/Side, Correct
Procedure (3 C’s) policy and standard. Expansion of implementation of policy and standard to Oral Health and
Radiation Therapy. Safe Blood Administration: standardised policy and competency checking for
nurses. Roll out of a standardised patient identification checking procedure. Labelling ‐ consistency of labelling.
Foreign object left in patients post procedure Quarantine time for checking /instrument count. Standardised processes for checking /instrument count.
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Strength of Recommendations Using the Patient Safety Centre “Strength of Recommendations” audit tool (Appendix 4), the strength of the recommendations analyses for this study listed below in Figure 57
Figure 57: Strength of Recommendations
Strength of Recommendations Number of Rec’s
Percentage
Recommendations with high effect / effort: 21 7%
Recommendations with moderate effect / effort:
72 25%
Recommendations with low effect / effort: 195 68%
Total 288 100%
The relative low number of recommendations with high effect / effort is primarily due to the high number of recommendations advising review / creation of policies and procedures (and all the other items under this category of recommendation), and the high number of recommendations identifying training and education.
Future Recommendations Analysis While the recommendations from RCA have been analysed for themes and emerging trends, there is a requirement to ‘close the loop’. For example, this analysis does not indicate whether the recommendations were implemented or not, and if so, whether they made a difference. This “closing of the loop” information is what is needed to develop an evidence base regarding what really makes health care safer. This being the case, the next and more important step regarding the analysis of clinical incident review data will be to determine if: The recommendations were implemented, and if not, why not? (Were, they for example, too difficult to implement or were there insufficient
resources to implement them?) Did implementing the recommendations make a difference? Was the desired
outcome achieved? If not, why not? Were there unexpected outcomes? If so, what were they?
The next part of this body of work is currently underway.
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Appendix 3: A review of the 2008 Mental Health Incident Analyses Data presented here is generated from all Severity Assessment Code 1 (SAC1) mental health clinical incidents that were analysed and reported to PSC in 2008. This data is not aligned with the reporting period for this edition of Learning to Action (being aligned with a calendar year rather than a financial year), but is included here because the findings and analysis can be validly generalised. Information includes: types of clinical incident analysis methodology employed recommendation themes the (de‐identified) recommendations by clinical category
Methodology For suspected suicides of mental health consumers receiving inpatient care (this includes care provided in the Emergency Department and inpatient consumers who have died while on approved leave or absconding from an inpatient unit), the mandatory incident analysis methodology is Root Cause Analysis (RCA). RCA is not mandatory when the SAC1 event pertains to the suspected suicide of a consumer under the care of a community mental health service. When a RCA is not carried out, some other form of clinical incident analysis such as a Human Error and Patient Safety (HEAPS) analysis takes place. In 2008, the Patient Safety Centre received notification of 79 mental health SAC1 events. Three of these notifications pertained to incidents which occurred in 2007. The incidents reported fall under the following clinical categories:
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Figure 58: Categories of Mental Health SAC 1 Events ‐ 2008
Clinical Category Number of SAC1
Suspected suicide in the community of a person under the care of a mental health service
52
Suspected suicide of a patient receiving inpatient healthcare – death occurred in a mental health facility
1
Suspected suicide of a patient receiving inpatient healthcare – death occurred during approved leave
3
Suspected suicide of a patient receiving inpatient healthcare – death after absconding
6
Other (suspected suicide unless otherwise indicated):
Cause of death uncertain ‐ ? suicide or natural causes 1
Cause of death uncertain ‐ ? suicide or accident 1
Cause of death uncertain ‐ ? suicide or over dose 1
Episode of care uncertain ‐ ? patient open or closed to MHS 2
Pt was closed to service but discharged within 30 days of death
1
Patient was awaiting assessment 2
Patient alleged to have committed homicide 1
9
Total In‐Scope Suspected suicides 71
Figure 59: Incidents reported, but out of Scope for analysis
Incidents reported and out of scope for this report
Death later determined not to be suicide (4) 4
Patient was not a MHS consumer (2) 2
Patient closed to MHS more than 30 days before death (1) 1
Incident involved a siege – no death (1) 1
Total out of scope reported events: 8
Of the 71 Mental Health SAC1 incidents that were considered for this study, 63% (n = 45) had incident analysis reports submitted to the PSC by July 1st 2009. The incident analysis methodology used to review the 45 MH SAC1 incidents was as follows:
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Figure 60: Analysis Methods for Mental Health SAC 1 events
Analysis Type Count %
RCA 18 40%
HEAPS 10 22.2%
Critical Incident R/V using known incident analysis structure 10 22.2%
Critical Incident R/V using unknown incident analysis structure
5 11.1%
RCA process cancelled (no further information) 2 4.5%
Total 45 100%
Findings A total of 152 recommendations were considered in this study. If a given recommendation was repeated in subsequent clinical incident analyses in the same district, the recommendation was only counted once. The recommendations can be classified under the following themes:
Figure 61: Themes identified in Recommendations about Mental Health Events
Theme
Continuity of care This includes: handover; transfer processes; discharge planning and processes, follow up care; and, communication among staff / care providers.
Workforce Issues.
This includes: training; education; orientation; supervision; staffing levels; workload; skill mix; rostering; scope of practice; staff roles; credentialing; fatigue; and, team composition
Policies and procedures.
This includes the development, review, implementation and oversight of: policies; procedures; protocols; workplace instructions; guidelines; clinical pathways; and, workplace practice instructions not otherwise specified.
Documentation, Including medical records, electronic clinical information systems.
Assessment Includes particular reference to risk assessment and screening.
Emergency Department. Relates to care in emergency departments.
Capital works Modification of environment / equipment and number of beds.
Dual diagnosis and management of drug and alcohol issues.
MHA2000.
Other.
These are recommendations which are specific to the particular incident under review and which do not fit well into any of the other prevalent categories
Medication.
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Figure 62: Frequency of Themes identified in Recommendations about Mental Health Events
Recommendation Theme # of times Theme counted
% of times theme was counted
Continuity of care 68 22%
Workforce issues 58 19%
Policies and procedures 56 18%
Documentation, medical records, electronic clinical information systems
38 12%
Assessment 31 10%
Emergency Department 18 6%
Capital works / Environment / Equipment and Bed numbers
9 3%
Dual diagnosis and management of drug and alcohol issues.
9 3%
MHA2000 8 3%
Other 7 2%
Medication 6 2%
Total number of themes counted: 308 100%
Discussion It is useful to analyse the recommendations that have been made following clinical incident analysis. The primary use of this information is to assist health service providers, managers and policy makers to see where gaps in safe service delivery exist; and then to respond to these issues to reduce preventable patient harm. Additionally, it is expected that this information will be used as a reference during clinical incident review when working with clinical incident analysis teams. Many districts encounter the same sorts of incidents. It can be validating to see that other districts are choosing to employ similar strategies to address problems identified. It can also be inspiring to see an innovative approach which has not been tried earlier and which may be applicable to one’s own service. The sharing of this information will assist in planning for improved, safer, evidence based mental health service delivery.
Outcome from Incident Review: Incident review using known incident analysis methodology / structure (RCA, HEAPS or critical incident review which includes breakdown of HEAPS factors) yielded recommendations or lessons learnt at least 90% of the time. Use of an unknown
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incident analysis methodology (a RCA or HEAPS was not conducted and no information is provided regarding what type of incident analysis took place other than that a clinical or incident review occurred) yielded recommendations or lessons learnt 20% of the time. This is an issue for consideration by mental health services when determining the type of incident methodology to employ when reviewing the suspected suicide of consumers under the care of a community mental health service, where RCA is not mandatory.
For the future While the information presented above is interesting, it is of limited utility. For example, this information does not indicate whether the recommendations were implemented or not, and if so, whether they made a difference. This “closing of the loop” information is what is needed to develop an evidence base regarding what makes mental health care safe.
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Appendix 4: Strength of Recommendations Not all recommendations made after incident analysis are equal. It is possible to achieve better outcomes by implementing strong recommendations. A recommendation is “strong” when it is highly likely to achieve its desired impact. Examples of strong recommendations include physical changes to the workplace or equipment, standardisation or process redesign to simplify and reduce risk. However, even amongst “strong” recommendations, not all are equally desirable. Some very strong recommendations are extremely expensive and effort‐intensive to implement, whilst others are simple, inexpensive and efficient. Consideration of both “strength” and "effort" guides the selection of recommendations to ensure maximum impact.
Figure 63: Strength of Actions
High Effort
Least Desirable:
Low Impact High Impact
Most Desirable
Low Effort
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