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Publication Index

CEC Publications

This is an index of general publications issued by the Clinical Excellence Commission. For more specific information please visit our Programs Index.
  • TOP 5: Improving the Care of Patients with Dementia 2012 - 2013 Research Report

    TOP 5: Improving the Care of Patients with Dementia 2012 - 2013 Research Report

    People with dementia who are admitted to hospital can find themselves in environments that result in heightened distress and anxiety for vulnerable patients. Carers of patients with dementia are an invaluable source of 'tips' and personal information that can be used by clinicians to improve care and allay distress for the patient with dementia.

    This TOP 5 research study indicates that the use of a low cost, patient based communication strategy for patient care is associated with significant improvements in patient outcomes, safety, carer experience and staff satisfaction while providing potential cost savings to health services.

    • TOP 5: Improving the Care of Patients with Dementia 2012 - 2013 Research Report is available
  • Clinical Focus Report - Vacuum Assisted Births - Are We Getting in Right? A focus on subgaleal haemorrhage

    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 Patient Safety Team and NSW Kids and Families collaborated to review data from January 2001 to December 2012.

    Data was obtained from the Incident Information Management system (IIMS); International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) coding; Newborn and paediatric Emergency Transport Service (NETS) retrieval data; device information from the Therapeutic Goods Administration (TGA); Root Cause Analyses (RCA); and available reports from coronial inquiries. The report outlines the findings from this analysis, identifies key contributing factors to neonatal trauma and makes recommendations for system improvement.

    • Clinical Focus Report - Vacuum Assisted Births - Are We Getting in Right? A focus on subgaleal haemorrhage - PDF ~ 770kB
  • 2013 QSA NSW Statewide Report

    Quality Systems Assessment (QSA) Safer Systems Better Care, 2013 report

    Safer Systems Better Care (2013) is the sixth annual report of the Quality Systems Assessment (QSA) Program. This report demonstrates local commitment to clinical risk management and continuous learning at all levels and right across the NSW health system.

    Challenging our systems of safety and quality and how they translate into clinical practice at the patient level is an important part of the QSA process. Results from the 2013 process reaffirmed the strength of systems to support patient safety and clinical quality in NSW. The report identifies seven recommendations for proactive local improvement that the CEC will support by working with local teams and system-level partners.

  • NSW Mortality Review: The Way Forward

    NSW Mortality Review: The Way Forward (July 2014)

    Patients admitted to NSW hospitals receive a high standard of care by dedicated professionals who are committed to quality and safety. Unfortunately, every day patients die in our hospitals and while some of these deaths are expected, some are not. This compendium has been compiled to provide direction and supporting resources for clinicians and managers within the NSW health system in relation to mortality review. Its aim is to facilitate a standardised approach to mortality review.

  • KIDCAP child resistant packaging information sheet

    Child-Resistant Packaging - KIDCAP

    Some medicines can cause serious harm, even death, if they are accidentally ingested by infants or children. Child-resistant packaging is designed to limit or delay access to medicines. A warning code, KIDCAP, has been added to i.Pharmacy systems in NSW. This information sheet provides pharmacy staff with information about the warning code and the provision of child resistant packaging.

    • KIDCAP child resistant packaging information - PDF ~345kb
  • Chartbook on Safety and Quality in Health Care in NSW 2009

    Chartbook on Safety and Quality in Health Care in NSW 2010

    The 2010 Chartbook includes a new chapter on Cancer Services (surgical volumes); and expands certain existing indicators (e.g. Population Health, Ambulance Services, Aboriginal Health and CEC initiatives in safety and quality). Again, new presentation formats have been introduced, this time to portray the data by the new local health districts. - Published, July 2012

  • Chartbook on Safety and Quality in Health Care in NSW 2009

    Chartbook on Safety and Quality in Health Care in NSW 2009

    The 2009 Chartbook includes two new chapters on Patient Experience and Cancer Services (incidence and mortality); and expands certain existing indicators (e.g. Population Health, Mental Health Services, Ambulance Services, Aboriginal Health and CEC initiatives in safety and quality). New presentation formats have also been debuted. - Published, December 2010

  • Chartbook on Safety and Quality in Health Care in NSW 2008

    Chartbook on Safety and Quality in Health Care in NSW 2008

    The 2008 Chartbook offers information on access to services; the appropriateness, effectiveness and safety of care; efficiency of service provision and consumer participation. It provides coverage of many types of services from child and maternal care, to mental health care and emergency services. It spans clinical areas such as cardiac care and neonatal services. - Published, December 2009

  • Chartbook on Safety and Quality in Health Care in NSW 2007

    Quality of Healthcare in NSW: A Chartbook 2007

    The Chartbook aims to make the NSW health system better and safer for patients.

    Chartbook users please note an errata has been published. A revised edition of The Chartbook is available which incorporates the changes in the errata. For those with printed copies of Chartbook 2007, please print the errata page and keep it with the document. - Published, April 2008. Revised edition and errata published, July 2009

    • Quality of Healthcare in NSW: A Chartbook 2007 (Revised Edition) - PDF ~1.0mb
    • Chartbook 2007 Errata - PDF ~36kb
    • How to Use The Chartbook - PDF ~24kb
  • Publication cover

    Incident Management in the NSW Public Health System - Six-monthly Report Series

    This report provides information on clinical incidents reported in the NSW health system . This work is part of the Clinical Excellence Commission's contribution to the NSW Patient Safety and Clinical Quality Program (PSCQP) established in 2004. - Published, December 2009

  • Publication cover

    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

  • Clinical Focus Report - Falls

    Clinical Focus Report - Falls

    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.

  • Clinical Focus Report - Retrieval And Inter-Hospital Transfer

    Clinical Focus Report - Retrieval And Inter-Hospital Transfer

    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.

    • Clinical Focus Report - Retrieval And Inter-Hospital Transfer - PDF ~414kb
  • Clinical Focus Report - Patient Controlled Analgesia

    Clinical Focus Report - Patient Controlled Analgesia

    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.

    • Clinical Focus Report - Patient Controlled Analgesia - PDF ~772kb
  • Clinical Focus Report - A Review of Acute Coronary Syndrome Incidents

    Clinical Focus Report - A Review of Acute Coronary Syndrome Incidents

    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.

    • Clinical Focus Report - A Review of Acute Coronary Syndrome Incidents - PDF ~567kb
  • Clinical Focus Report: Fetal Monitoring: Are we getting it right?

    Clinical Focus Report: Fetal Monitoring: Are we getting it right? April 2013

    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 multifaceted contributory factors related to suboptimal fetal monitoring.

    • Clinical Focus Report: Fetal Monitoring: Are we getting it right? - PDF ~685kb
  • CEC's Patient Safety Program

    Fractured Hip Surgery in the Elderly July 2011

    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.

    • Fractured Hip Surgery in the Elderly July 2011 - PDF ~780kb
  • CEC's Patient Safety Program

    Diagnostic tests - How access and follow-up affect patient outcomes September 2011

    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.

    • Diagnostic tests - How access and follow-up affect patient outcomes - PDF ~982kb
  • CEC's Patient Safety Program

    Clinical Focus Report - Review of Clinical Incident Reports Recognition and Management of Sepsis © CEC 2012

    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.

    • Clinical Incident Reports Recognition and Management of Sepsis - PDF ~1.08mb
  • CEC's Patient Safety Program

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

    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.

    • Clinical Incident Reports Clinical supervision at the point of care - PDF ~676kb
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    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
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    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
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    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
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    CEC Directions Statement

    The CEC Directions Statement outlines the role of the CEC in the NSW Patient Safety and Clinical Quality Program, the principles underpinning the program and the governance and activities of the Clinical Excellence Commission. - Published, August 2004