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Programs NSW Patient Safety

This program is current
Patient Safety NSW

The CEC's Patient Safety Program is aligned with the NSW Patient Safety and Clinical Quality Program, which seeks to deliver a standardised, system-wide approach to ongoing improvements in the safety and quality of health care provided across the NSW health system. A key component is analysis of Statewide clinical incident data within the Incident Information Management System.

An important part of the patient safety program is to inform and work with NSW Health, local health districts and clinical groups to address the patient safety issues identified during review of aggregated data.


Program Overview

Background

The Patient Safety team utilises the electronic Incident Information Management System (IIMS) to identify risks to patient safety, as reported by NSW Health staff. These insights help to determine where Statewide improvements to clinical care can be made. The information obtained from IIMS data analysis has been the basis for many CEC projects and continues to highlight emerging issues across the public health system.

IIMS provides a wealth of information about the way NSW Health staff address risks to safe and effective patient care. Root Cause Analysis (RCA) of serious incidents provides further detail of where clinical care systems can fail. The team recognises that the greatest benefit of the incident reporting system is provision of timely and open feedback to clinical staff, their managers and the patients and families they care for. In this way we can work together to provide the high level of clinical care for which NSW Health is recognised.

CEC's Patient Safety Publications

Incident Management Report Series

These reports provide information on clinical incidents reported in the NSW health system and some of the actions taken in response. This work is part of the Clinical Excellence Commission's contribution to the NSW Patient Safety and Clinical Quality Program (PSCQP) established in 2004. Reports contain information on clinical incidents reported in the NSW health system. Future reports in this series will be released in a data dashboard format. This will contain links to projects and programs developed in response to clinical incident reporting, so that readers will have the most recently available information about each of these programs.

 

Patient Safety Webinars

2013 Patient Safety Webinar Series schedule to be advised. Contact: PatientSafety@cec.health.nsw.gov.au

 

Clinical Focus and Patient Safety Reports

The following reports are prepared by the CEC 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, such as the Sepsis Kills Project link, as well as raising awareness at the clinical level. The reports also contain recommendations for system-wide improvements.

 


  • Clinical Focus Report - Falls

    Clinical Focus Report - Falls - PDF ~713kb

    Falls are the most commonly reported incident type in the NSW public health system and recognised as posing significant risk to the wellbeing of patients. Patients who fall in hospital often have more than one chronic condition. The findings of this report highlight the importance of considering a patient's risk of sustaining fall injury, not just risk of falling.

    For more information about how the NSW Health system is working to reduce falls and fall injury, go to the Falls Prevention Program web-page now available

  • Clinical Focus Report - Retrieval And Inter-Hospital Transfer

    Clinical Focus Report - Retrieval And Inter-Hospital Transfer - PDF ~414kb

    This report amalgamates findings from the review of the Incident Information Management System (IIMS), root cause analysis (RCA) reports and workshops conducted on this issue. The report gives context, and degree of understanding, to the frustration expressed by many clinicians arranging inter-hospital patient transfers. In most instances patients are transferred safely and quickly and receive the care they need. Some of the most challenging transfers reported were those where patients required urgent access to specialist care. The persistent effort of staff to get the best care for their patients and the challenges faced was evident in the data.

    For more information about how the NSW Health system is working to improve retrieval and inter-hospital transfer of patients, go to NSW Health Policy PD2011_031 now available

  • Clinical Focus Report - Patient Controlled Analgesia

    Clinical Focus Report - Patient Controlled Analgesia - PDF ~772kb

    PCA is becoming increasingly utilised for controlling pain. It is safe and effective providing there is careful planning. The review identified that patients receiving PCAs may be at significant risk and many require additional unplanned care while receiving PCA. The report suggests there is need for greater governance around PCA and its implementation processes. Recommendations for consideration are provided within the report.

    For more information about how the NSW Health system is working to improve the management of patient controlled analgesia, go to the ACI web-page now available

  • Clinical Focus Report - A Review of Acute Coronary Syndrome Incidents

    Clinical Focus Report - A Review of Acute Coronary Syndrome Incidents - PDF ~567kb

    This aggregated review of root cause analysis reports related to the diagnosis and management of patients with an Acute Coronary Syndrome (ACS), provides information about contributing factors and helped to raise awareness of these across the NSW Health system. Much work, including clinical guidelines, has subsequently been done to try and reduce this risk to patient safety.

    For more information about how the NSW Health system is working to improve the diagnosis and treatment of patients presenting with ACS, go to the ACI web-page now available

  • Clinical Focus Report: Fetal Monitoring: Are we getting it right?

    Clinical Focus Report: Fetal Monitoring: Are we getting it right? April 2013 - PDF ~685kb

    Fetal monitoring is recognised as an important component of antenatal and intrapartum care. Despite rigorous surveillance, some babies are compromised and sustain significant injury or die during pregnancy/labour and delivery. This report analyses incidents notified within the Incident Information Management System (IIMS), identifying the multi-faceted contributory factors related to sub-optimal fetal monitoring.

  • CEC's Patient Safety Program

    Fractured Hip Surgery in the Elderly July 2011 - PDF ~780kb

    The information in this report has been de-identified and analysed in accordance with Incident Information Management System (IIMS) datasets and, where relevant, the classification sets used by the CEC and the Root Cause Analysis Review Sub-committees.

    For more information about how the NSW Health system is working to improve the treatment of elderly patients with hip fractures, go to the ACI web-page now available

  • CEC's Patient Safety Program

    Diagnostic tests - How access and follow-up affect patient outcomes September 2011 - PDF ~982kb

    The information in this report has been de-identified and analysed in accordance with Incident Information Management System (IIMS) datasets and, where relevant, the classification sets used by the CEC and the Root Cause Analysis Review Sub-committees.

  • CEC's Patient Safety Program

    Clinical Focus Report - Review of Clinical Incident Reports Recognition and Management of Sepsis © CEC 2012 - PDF ~1.08mb

    Sepsis and septic shock are life-threatening conditions which may be difficult to diagnose. This poses challenges for clinicians, because the early recognition and management of sepsis is crucial in terms of morbidity and mortality.

    For more information about how the NSW Health system is working to improve the diagnosis and treatment of patients with sepsis, go to the CEC Sepsis Program web-page now available

  • CEC's Patient Safety Program

    Patient Safety Report - Review of Clinical Incident Reports - Clinical supervision at the point of care © CEC 2012 - PDF ~676kb

    Clinical supervision is frequently defined as a formal process of professional support and learning which enables individual clinicians (medical, nursing and allied health professionals) to develop knowledge and competence and assume responsibility for their own practice (Cutcliffe & Butterworth 2001). The focus of this report, however, is point of care supervision.


    Other Publications

      Review of the Implementation of the NSW Health Open Disclosure Policy arising from the 2009 NSW Ombudsman's Report October 2012 - PDF ~780kb

      The Open Disclosure Implementation Review Committee has developed an implementation framework and made a number of recommendations regarding policy content and support.

      Giving a Voice to Patient Safety in New South Wales 2007 - PDF ~768kb

      This monograph is the final in a series prepared by the Centre for Clinical Governance Research at the University of New South Wales, for the Clinical Excellence Commission. The aim of the series is to shed light on what has become one of the most important questions in health care practice and management: what do we know about patient safety and what we can do about it?

      Patient Safety - A comparative analysis of eight inquiries in six countries October 2006 - PDF ~1.10mb

      This is a report of eight inquiries into alleged poor health care. Three are from Australia -Perth (King Edward Memorial Hospital), Melbourne (Royal Melbourne Hospital) and Sydney (Campbelltown-Camden). The others are from Scotland (Glasgow Victoria Infirmary), England (Bristol Royal Infirmary), Slovenia (Celje Hospital), New Zealand (Southland DHB) and Canada (Winnipeg Health Sciences Centre).

      Patient Safety Research - A review of the technical literature May 2005 - PDF ~804kb

      This monograph has been prepared as part of a program of research on safety and quality undertaken for the Clinical Excellence Commission (CEC) in New South Wales by the Centre for Clinical Governance Research at University of New South Wales. It seeks to assess the patient safety literature and suggest a way forward for clinical teams in providing safer healthcare.

    Archive Resources

      CEC's Patient Safety Program

      It's all about the understanding the narrative - PDF ~1.44mb

      This poster signals improving safety through analysing the content of incident reports and investigations. It was presented at the 2012 BMJ/IHI Quality and Safety Conference in Paris. The CEC Patient Safety Team is able to view, in a de-identified format, all clinical incidents reported into the State-wide electronic incident management systems (IIMS) by the staff at the 220+ public hospitals and their affiliated services.

      Thumbnail poster

      Communicating for Clinical Care Poster - PDF ~691kb

      This poster looks at the progress of incident management in NSW. In order to implement a standardised coordinated approach to incident management across a Statewide health system, it addresses the processes of incident management, staff training issues, Incident Information Management System (IIMS) progress, how incident information flow is managed in NSW and how the new "statistical process model"™ is now allowing the State Reportable Incident Review Committee to address the issues and actions required. The poster also reveals how the CEC is using data to drive change, especially in relation to medication errors.

      Thumbnail poster

      Data as Information - A Power Tool in Cultural Change Vision for patient safety in NSW - PDF ~321kb

      This poster presentation discusses how the CEC is implementing the vision for Patient Safety in NSW and fostering a culture of openness, in which errors are acknowledged and reported. It briefly explains the Incident Information Management System (IIMS), how incidents are assessed, outcomes, and incident notifications according to a Principal Incident Type (PIT). It poster also mentions the model policy established by the NSW Quality and Safety Branch, in conjunction with key stakeholders, to address "wrong patient, wrong procedure, wrong site incidents".

      Thumbnail poster

      Data as Information - A Power Tool in Cultural Change Safety Improvement Program Patient Safety and Clinical Quality Program - PDF ~713kb

      This poster presentation discusses how the CEC aims to implement a standardised, co-ordinated approach to incident management across a Statewide health system through two initiatives - the Safety Improvement Program and the Patient Safety and Clinical Quality Program. Information about these programs includes further details on root cause analysis training, establishment of RIBs to provide timely escalation, the implementation of IIMS, feeding data back to the system as information, incident management in NSW and outcomes from evaluations.