Top 3 system factors
The system issue of ‘Care Planning’ was identified as a significant factor impacting on the risk of a patient experiencing a serious adverse event. It relates to where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team. This includes care co-ordination and high-risk system issues within a facility or between health care facilities. Care Planning also includes where a patient's risk factors (‘High Risk not considered’) have not been adequately assessed or managed.
Poor communication and inadequate assessment of risk were also identified as top contributory system factors from serious incident investigations over the last 5 years. The most recently publish report from the CEC (Biannual Incident Report January -June 2021), indicates that care planning and communication are the top system factors identified contributing to adverse events occurring across the state.
Care planning
Poor communication
Inadequate assessment of risk
0 50 100 150 200
Communication
Timing and Access 18.1%
It is interesting to note that communication was also seen as key finding from complaints received from our patients and consumers.
Communication 31.7%
Top 5 principal incident type The system issue of ‘Care Planning’ was identified as a significant factor impacting on the risk of a patient experiencing a serious adverse event. It relates to where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team. This includes care co-ordination and high-risk system issues within a facility or between health care facilities. Care Planning also includes where a patient's risk factors (‘High Risk not considered’) have not been adequately assessed or managed. Poor communication and inadequate assessment of risk were also identified as top contributory system factors from serious incident investigations over the last 5 years. The most recently publish report from the CEC (Biannual Incident Report January -June 2021), indicates that care planning and communication are the top system factors identified contributing to adverse events occurring across the state. Top 3 system factors Clinical care, treatment and safety 38.1% Management of facilities 6.8% Improvement opportunities to strengthen communication 31.7% of patients and consumers have provided feedback that their experience of care has been affected by miscommunication between staff from departments, or lack of or poor communication received by patients regarding their care plan and their discharge instructions. Source: Thematic review of compliments and complaints reported on ims+ (1 June 2021 - 31 May 2022). The role of the Consumer Peer Worker employed across MHDA services. These Peer workers provide lived expertise to service decision making, the development initiatives through committee representation, consultation, co-designing and co-producing projects, and co-facilitate training and education. Elevating the Human Experience Program which involve working with patients, their families and carers to improve the performance of health systems and most importantly, delivering better health outcomes for patients. The Best Care Together Program at RNSH Safety Huddles - A multidisciplinary process ensuring that the entire team is mindful of the tasks that need to be completed by each team member Intentional Patient Rounding is purposeful hourly communication by a healthcare team member with each patient and/or their carer or family. The aim of this: Keeps patients and/or their carer or family informed about and involved in their care Supports the delivery of safe, quality care Regularly evaluates the quality of care delivered Creates trust and reduces patient and/or carer or family anxiety by providing clear expectations for each interaction by a known care giver Speaking up for Safety Across NSLHD there continues to be several strategies which have been implemented to improve communication between clinical teams and between clinicians and patients/family/carers. These include:
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