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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.

Patient safety poster

Poster introducing the electronic Incident Information Management System (IIMS)

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 how 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 patient safety 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.

Incident Managment Report Series

Six-monthly Reports

The report on Clinical Incident Management in the NSW Public Health System for July to December 2009 is now available. This report provides 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. Information on clinical incidents reported in the NSW health system is available below.

Analysis of first year of IIMS data Annual Report 2005-2006

Released by the Minister for Health on 20 December 2006, this inaugural report provides an overview of the first complete year of statewide IIMS data, with a focus on clinical notifications. The report provides valuable insights into the nature and number of clinical incident notifications occurring in the system, and a platform for sustainable clinical improvements. Similar reports will be published annually. - Published, December 2006

  • Analysis of first year of IIMS data Annual Report 2005-2006 - PDF ~1.10mb

This report complements the Patient Safety and Clinical Quality Program: Third Report on Incident Management in the NSW Health Public Health System 2005-2006 - PDF ~265kb

Patient Safety Webinars

Program for 2011/12

  • Considering Human Factors in the Development of Forms, Labels and Checklists - Mon 12 Sep, 2011 1330-1430
  • Further webinars to be advised.

Webinars Currently Available for Review

To access the audio component, please dial:

  • International: (+61) 3 9221 4752
  • Within Australia: (03) 9221 4752
and enter 778 715 when prompted. The audio recording will be available until the 12th of October 2011.

Publications

The Clinical Focus Report entitled - Diagnostic Tests - How access and follow-up affect patient outcomes

This report was prepared by the Clinical Excellence Commission (CEC) Patient Safety Team.Analysis of aggregated de-identified information from the NSW Incident Information Management System (IIMS) is one of our best tools to identify potential gaps in quality care. We also evaluate root cause analyses conducted after serious clinical incidents. Possible solutions for the issues identified are developed and validated by clinical staff and managers. This is coordinated by the CEC and the Clinical Risk Review Committee.

This report is one of a series developed from this analysis process. Previous analyses and reports have triggered system-wide improvements, such as the Sepsis Kills Project, as well as raising awareness at the clinical level. This report, on access and use of diagnostic test results, also contains recommendations for system-wide improvements.

The reports contains a QR Code on the inside cover, so that staff reading the report can obtain further copies from the CEC website. - Published, September 2011

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

Patient Safety Report from Review Of Clinical Incident Reports - Fractured Hip Surgery in the Elderly

This report was prepared by the Clinical Excellence Commission (CEC) Patient Safety Team. The information it contains 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.

The reports contains a QR Code on the inside cover, so that staff reading the report can obtain further copies from the CEC website.- Published, July 2011

Giving A Voice To Patient Safety In New South Wales

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? - Published, October 2007

  • Giving A Voice To Patient Safety In New South Wales - PDF ~768kb

Patient Safety - A comparative analysis of eight Inquiries in six countries

This is a report of eight Inquiries into alleged poor health care. Three are from Australia: from Perth (King Edward Memorial Hospital), Melbourne (Royal Melbourne Hospital) and Sydney (Campbelltown-Camden). The remainder are from Scotland (Glasgow’s Victoria Infirmary), England (Bristol Royal Infirmary), Slovenia (Celje Hospital), New Zealand (Southland DHB) and Canada (Winnipeg Health Sciences Centre). - Published, October 2006

  • Patient Safety - A comparative analysis of eight Inquiries in six countries - PDF ~1.10mb

Patient Safety Research - A review of the technical literature

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. - Published, May 2005

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

Resources

  • Thumbnail poster

    Continuous Change in Incident Management - A NSW Journey

    This poster looks at the progress of Incident Management in NSW. In order to implement a standardised coordinated approach to incident management across a state wide health system, this poster addresses the processes of incident management, staff training issues, Incident Information Management System (IIMS) progress, how Incident information flow are 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. This poster also reveals how the CEC is using data to drive change, especially in relation to medication errors.

    • Communicating for Clinical Care Poster - PDF ~691kb
  • Thumbnail poster

    Data as Information - A Power Tool in Cultural Change

    Vision for patient safety in NSW

    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). This 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

    This poster presentation discusses how the CEC aims to implement a standardised coordinated 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 include further details on root cause analysis training, establishment of RIB's to provide timely escalation, the implementation of IIMS, feeding data back to the system as information, Incident Management in NSW and outcomes from evaluations.

    • Safety Improvement Program Patient Safety and Clinical Quality Program - PDF ~713kb

 

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