FEBRUARY 2025 Key Learnings from Serious Incident Reviews
EDITION 37
Clinical Governance Standard
The Clinical Excellence Commission (CEC) regularly publishes insightful learnings from reviews of serious incidents across NSW. You can explore these valuable resources on the CEC website -Serious Incident Review page. Highlights from Recent Publications 1. Alarm Fatigue in Cardiac Monitoring - Patient Safety Watch (December 2024). The latest issue of Patient Safety Watch focuses on the critical issue of alarm fatigue. A review using Human Factors thematic analysis of several recent Serious Adverse Event Reviews (SAERs) uncovered some lessons for learning relating to alarm fatigue. Key cases highlight: The overwhelming number of Alarm Systems can lead to a high prevalence of audible alarms in the clinical setting resulting in alarm fatigue. Excessive alarms can desensitise staff, leading to missed critical alerts. Examples where alarm fatigue contributed to delayed responses and adverse patient outcomes. Several strategies to streamline alarm systems and improve response times are proposed. 2. Learnings Summary - Mental Health, Alcohol, and Other Drugs - July to September 2024 This document provides a summary of learnings arising from the Mental Health and Alcohol and Other Drug Serious Incident Review (SIR) Sub-Committee meetings held July - September 2024. Key learnings include: Speaking Up for Safety: Empowering all healthcare staff to advocate for patient safety. Leave Planning: Importance of proper documentation and risk assessments for unescorted leave. Discharge and Transfer of Care: Ensuring warm handovers and clear communication during care transitions. Y our paragraph text Communication: Continuous vigilance and clear communication to manage suicide risks. Care Planning: Comprehensive safety plans and reassessment of patients, especially those with opioid dependency.
For more detailed insights and to stay updated on best practices, visit the Clinical Excellence Commission’s Serious Incident Review page.
News from the Australian Commission on Safety and Quality in Healthcare
The National Medicines Symposium (NMS24) in November 2024 brought together leading experts, clinicians and policymakers to explore key challenges and opportunities in medication safety and quality. If you missed this insightful event, recordings are now available on essential topics such as: Practical deprescribing strategies Patient-centred prescribing practices Harnessing digital health for safer medicine use Hear from renowned speakers, including Professor Jennifer Martin, Dr Lisa Kouladjian O’Donnell, Professor Sarah Hilmer AM and Professor Melissa Baysari, as they share insights to enhance medication management across healthcare systems. Catch up on NMS24: Watch the recordings
Summit on clinical governance in digital health The C3.0 Connect. Care. Confidence.2025 Summit took place on 18 February 2025, shaping the future of clinical governance in digital health. Co-hosted by the Australian Digital Health Agency and the Australian Commission on Safety and Quality in Healthcare, this interactive summit brought together leading experts, clinicians, service providers and consumers. Videos of the event are available on the digitalhealth.gov.au website. Sessions included Gen AI’s impact on patient safety, building a digitally enabled workforce, person-centred care through safe technology, and consumer co-design approaches.
Made with FlippingBook - professional solution for displaying marketing and sales documents online