Between the Flags - Keeping patients safe
The Clinical Excellence Commission (CEC) in collaboration with the NSW Health Quality and Safety Branch (QSB) commenced a significant body of work to address the internationally recognised need for clinicians to identify and manage early, deteriorating patients as detailed in the Project Overview.
The early phase of the project build commenced in November 2007 and will be addressed in two (2) phases – with the initial phase focussing on diagnostics, and the later phase identifying, testing and evaluating possible solutions to this frequently-encountered problem. These earlier phases will be conducted over an eight (8) month project timeframe.
Program Overview
Background
The importance of this issue is undisputed. The National Health Service in the UK has recently undertaken similar work to address this internationally recognised issue.
According to NSW Health IIMS data (March 2007)1,2,3, the majority of SAC 1 clinical incidents are attributable to the following top four (4) identified factors across the spectrum of public hospitals:
- 1. Inadequate/poor communication (25%)
- 2. Lack of/poor compliance with policies and procedures (25%)
- 3. Knowledge, skills and competence issues (18%)
- 4. Problematic work environments/scheduling (14%)
The above data is further supported by an examination of the clinical management reviewed in 178 RCA's over a targeted three (3) month period (Oct-06 to Dec-06) where the top three (3) reasons for inadequate patient management leading to RCA1,2,3 were identified through the following:
- 1. Clinician failure to properly diagnose (31%)
- 2. Clinician failure to institute the appropriate treatment (19%)
- 3. Management of complications (15%)
Project Participation
In undertaking this project, the CEC will commence working intensively with facilities across the state from a representative sample of facility types in the initial two phases of the project:
- Tertiary (Principal Referral hospital)
- Major Metropolitan hospital
- Rural Base hospital
- Rural hospital
Following a high level of interest and response to EOI to participate in the project by all Area Health Services, five (5) facilities have been nominated to participate in this collaborative project over the next six (6) months - these facilities are as follows:
- 1. St Vincent's Hospital, Sydney
- 2. Canterbury Hospital
- 3. Port Macquarie Base Hospital
- 4. Wagga Wagga Base Hospital
- 5. Macksville District Hospital
Project details
We look forward to updating you on all the NEW developments around this very significant body of project work over the next 6 months.
In the meantime, should you require any further information, please do not hesitate to contact the following CEC staff coordinating this project:
Kimberley Fitzpatrick
Project Coordinator, CPI Projects
(02) 9382 7822
Kimberley.Fitzpatrick@cec.health.nsw.gov.au
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