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Programs Between the Flags - keeping patients safe

This program is current
Logo - two surf life saving flags

The CEC in collaboration with the NSW Quality and Safety Unit (QSU – formerly QSB) commenced Between the Flags to address the internationally recognised need for clinicians to identify and manage early, deteriorating patients.

The early phase of the project build commenced in November 2007 and will be addressed in two (2) phases – with the initial phase focusing 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.

Interim Project Report

Thumbnail, Interim Project Report

Program Overview

A detailed project overview of Between the Flags is available to download - PDF ~44kb | RTF ~7kb

Background

The importance of this issue is undisputed, Council Of International Hospitals - PDF ~196kb | RTF ~40kb.

The National Health Service in the UK has recently undertaken similar work to address this internationally recognised issue - PDF ~391kb | RTF ~68kb.

According to Incident Management in the NSW Public Health System (IIMS) March 2007 data 1, 2 and 3, the majority of SAC 1 clinical incidents are attributable to the following top four 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 month period (Oct-06 to Dec-06) where the top three reasons for inadequate patient management leading to RCA1, 2 and 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 facilities have been nominated to participate in this collaborative project over the next six months - these facilities are as follows:

  • St Vincent's Hospital, Sydney
  • Canterbury Hospital
  • Port Macquarie Base Hospital
  • Wagga Wagga Base Hospital
  • Macksville District Hospital

Resources

Initial Presentation

  • Presentation on the initial steps in the Recognition and Management of the Deteriorating Patient Project (RMDP) - PPT ~197kb | RTF ~3kb

Publications

Reports

  • Between the Flags: The Way Forward - PDF ~128kb | RTF ~154kb
    This report describes the agreed way forward to implement statewide change to help keep patients safe.
  • Between the Flags Interim Project Report - PDF ~1.63mb | TXT ~214kb
    A project report on the statewide initiative on the recognition and management of the deteriorating patient.

Contact

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:

Colette Duff
Acting Project Officer
(02) 9382 7833