APRIL 2023
EDITION 24
Clinical Governance Standard
NSLHD CLINICAL AUDIT SCHEDULE
The NSLHD Clinical Audit Schedule has been developed for all sites and services within NSLHD to support the monitoring and evaluation of clinical care processes and to provide support for clinical quality improvement activities across NSLHD. Download the complete 2022-23 NSLHD Clinical Audit Schedule. Note: The Schedule is divided into three categories (NSLHD acute, sub-acute, MHDA and PACH). Visit the clinical audit intranet page for more information. Clinical audits required to be completed this month are listed below.
April 2023 QARS Audits (entry links)
NSLHD_3_Infection Prevention Control Program compliance NSLHD_03_Transmission Based Precautions NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA)
St 3
St 4
NSLHD_05_ Falls Audit Documentation and Observation_Inpatient and MHDA NSLHD_05_Falls Design and Structure_Inpatient and MHDA NSLHD_05_Falls Audit Documentation_Community and Ambulatory Care Locations NSLHD_05_Falls Design and Structure_Community and Ambulatory Care Locations NSLHD_05_Post Partum Haemorrhage (PPH) Audit (RNSH | HKH Birthing | HKH Maternity) NSLHD_06_Perioperative Specimen Collection (RNSH Ambulatory Care | RNSH OT | Ryde OT | HKH OT ) NSLHD_06_Clinical Procedure Safety Checklist Audit - Level 3 procedures HKH OT | HKH Medical Imaging | RNSH ASB OT / Anaesthetics | RNSH Maternity Theatre | RNSH Burns Theatre | RNSH Medical Imaging | RNSH Endoscopy | RNSH Cardiac Cath Lab | RNSH Pain Management | Ryde OT NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA | PACH-HITH)
St 5
St 6
St 8
POLICIES, PROCEDURES AND GUIDELINES New, updated and recently published district-wide PPGs. Click on the links below to download documents from the Prompt document system. Refer to the NSLHD weekly bulletin in your inbox to access the most up-to-date list of PPGs Transitioning to Residential Aged Care from Hospital - NSLHD_procedure (new) Patient Identification Procedure - NSLHD_procedure (updated) Insulin Pen Use in Mental Health Drug & Alcohol Facilities: Safe Sharps Handling - MHDA_procedure (updated) Pressure Injury Prevention and Management Procedure - NSLHD_procedure (updated) Multiple Pregnancy Management - NSLHD_Guideline (new) Assessment and care for women diagnosed with Gestational Diabetes NSLHD_Guideline (new)
SAFETY ALERTS New, updated and recently published
Safety Alert (SA) - Requires immediate attention and action Safety Notice (SN) - Requires risk assessment at the district level Safety Information (SI) - Ensuring that lessons learned from state-wide, national or international sources are shared actively across NSW health system Updated: Clinician alert – Measles case in NSW - issued 6 April 2023 Disruption to supply: Heparin sodium (Pfizer®) 5000 units/5 mL injection ampoule - issued 4 April 2023 Disruption to supply: Suxamethonium chloride (Juno) 100 mg/2 mL injection - issued 4 April 2023 Updated: Use of Prone Restraint and Parenteral Medication in Healthcare Settings - issued 30 March 2023 Intravenous iron preparations and potential for skin staining - issued 29 March 2023 Updated: Paediatric stationary oxygen concentrator set-up - Absence of low flow alarm for flow rates less than 2 litres per minute - issued 28 March 2023
Medication Safety Updates including medication shortages are available on the CEC website.
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
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