Clinical Focus Reports
The following clinical focus reports are prepared by the CEC's 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, as well as raising awareness at the clinical level.
Recent Reports
Clinical Focus Report
Central Venous Access Devices and Air Embolism
Vascular air emboli related to management of a central venous access device (CVAD) are preventable patient safety events. A detailed review of incident data (January 2012 to April 2015) was undertaken to identify the frequency and contributory factors to these adverse events in NSW public hospitals.
The findings highlight common patient, clinical practice and system factors which have contributed to CVAD related air emboli. The report makes nine recommendations for system improvements.
Download PDF ~552KBClinical Focus Report
Hospital-Associated Venous Thromboembolism
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality, with hospitalisation being a major risk factor. A detailed review of data from January 2012 to December 2013 was conducted to identify cases of DVT and PE occurring during hospitalisation in NSW public hospitals.
Download PDF ~697KBClinical 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 and NSW Kids and Families collaborated to review data from January 2001 to December 2012.
The report outlines the findings from this analysis, identifies key contributing factors to neonatal trauma and makes recommendations for system improvement.
Download PDF ~770KBClinical Focus Report Library
- Acute Coronary Syndrome Incidents PDF ~567KB
- Clinical Supervision at the Point of Care PDF ~676KB
- Diagnostic tests - How access and follow-up affect patient outcomes PDF ~982KB
- Falls PDF ~713KB
- Fetal Monitoring: Are we getting it right? PDF ~685KB
- Retrieval and Inter-Hospital Transfer PDF ~414KB
- Patient Controlled Analgesia PDF ~772KB
- Recognition and Management of Sepsis PDF ~1.1MB