Clinical Focus Reports

The following clinical focus reports are prepared by the CEC's Patient Safety team and developed from analysis of aggregated de-identified information from the NSW Incident Information Management System (IIMS). Previous analyses and reports have triggered system-wide improvements, as well as raising awareness at the clinical level.

Recent Reports

Clinical Focus Report – Central Venous Access Devices and Air Embolism
Clinical Focus Report
Central Venous Access Devices and Air Embolism

Vascular air emboli related to management of a central venous access device (CVAD) are preventable patient safety events. A detailed review of incident data (January 2012 to April 2015) was undertaken to identify the frequency and contributory factors to these adverse events in NSW public hospitals.

The findings highlight common patient, clinical practice and system factors which have contributed to CVAD related air emboli. The report makes nine recommendations for system improvements.

DOWNLOAD ~552KB
Clinical Focus Report – Hospital Associated Venous Thromboembolism
Clinical Focus Report
Hospital-Associated Venous Thromboembolism

Venous thromboembolism (VTE) is a leading cause of morbidity and mortality, with hospitalisation being a major risk factor. A detailed review of data from January 2012 to December 2013 was conducted to identify cases of DVT and PE occurring during hospitalisation in NSW public hospitals.

DOWNLOAD ~697KB
Clinical Focus Report
Clinical Focus Report
Vacuum Assisted Births - Are We Getting in Right?
A focus on subgaleal haemorrhage

Subgaleal haemorrhage can occur during any birth, including normal vaginal birth and caesarean section, but is frequently associated with vacuum assisted births. The CEC and NSW Kids and Families collaborated to review data from January 2001 to December 2012.

The report outlines the findings from this analysis, identifies key contributing factors to neonatal trauma and makes recommendations for system improvement.

DOWNLOAD ~770KB