NSLHD’s Safety and Quality Newsletter provides information on new and upcoming activities, programs and initiatives within the district that aim to improve the safety of our patients and the quality of our care.
MARCH 2023
EDITION 23
IN THIS EDITION:
National Advance Care Planning Week Clinical Procedure Safety in the eMR Patient Safety Awareness Week Hospital Acquired Complications - new resources Human Factors: Complacency Project Spotlight - Save our Skin (RNS NICU) Cremation Risk Advice and Updated Death Certification Checklist - New Forms Patient Reported Measures
March 20-26 is National Advance Care Planning Week , a week dedicated to raising awareness of the importance of Advance Care Planning for everyone. Health professionals play an important role in understanding and respecting a person’s future healthcare preferences, for a time when they become seriously ill and are unable to communicate. Better outcomes are experienced by patients, carers, families and clinician’s when ACP is introduced early as part of routine care rather than in a crisis situation. Goals of Care planning in the healthcare setting involve discussion, negotiation and shared decision-making between the person, their person responsible and the healthcare team. Training & Education Resources for Health Professionals Supporting Health Professionals in Advance Care planning modules (Learning path) on My Health Learning. End of Life Essentials – 10 interactive, evidence based & peers reviewed modules End of Life Law for Clinicians NSLHD End of Life Care Intranet page Governance – Procedure & Guidelines Local and state governance documents to support clinicians with advance care planning and shared decision-making: End of Life Care and Decision-Making_GL2021_004 Clinical Principles for End of Life and Palliative Care_GL2021_016 End of Life Care Planning and Shared Decision-Making Advance Care Planning - MHDA Consent to Medical and Healthcare Treatment Manual
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CLINICAL PROCEDURE SAFETY in eMR Clinical Procedure Safety (CPS) addresses clinical care and patient safety risks associated with clinical procedures by improving the matching of the patient to the correct procedure and improving communication within the procedural team, and with the patients, they care for. From 28 February 2023, NSLHD has introduced a standardised electronic CPS Checklist in the electronic medical record (eMR) for Level 1 and Level 2 Clinical Procedures . The electronic CPS checklist supports clinicians in documenting and applying CPS principles to clinical practice so as to correctly match patients with their intended care approach. Find out more eMR PowerChart – Quick Reference Guide - Clinical Procedure Safety Checklist Level 1 & 2 How to navigate to the Clinical Procedure Safety Checklist iView section Where to find the Clinical Procedure Safety Checklist What are the CPS Checklist Data Elements? Clinical Procedure Safety Intranet page for resources such as CPS posters, links to policies, procedures, guidelines, link to definitions and more.
Patients, Carers and Families Information for patients, carers and families
Communicating for Safety Standard
Partnering with Consumers Standard
MARCH 2023
EDITION 22
Incident monitoring Lessons learned from Serious Incident Investigations Learnings from de-identified critical incidents across NSW highlights opportunities to improve care. Incidents reported in ims+ are reviewed to determine factors that contributed to the incident. In particular, serious harm incidents undergo formal investigations. Clinical auditing evaluate the effectiveness of the clinical care being provided and either confirm the quality of care or highlight areas of focus for improvement. It is an opportunity to check that "we are actually doing what we think we are doing". Health care staff can use clinical auditing to identify and measure areas of risk within their service. Clinical auditing PATIENT SAFETY AWARENESS WEEK Patient Safety Awareness Week is an Institute of Healthcare Improvement initiative held annually to encourage everyone to learn more about health care safety. According to the World Health Organization, one in every 10 patients is harmed while receiving hospital care. Preventing harm in healthcare settings is a public health concern. Everyone interacts with the healthcare system at some point in life and everyone has a role to play in advancing safe healthcare. The safety dimension of healthcare quality is defined as continuously improving the delivery of better health outcomes by minimising the risk and impact of unnecessary harm to patients. To ensure reliably safe, quality healthcare NSLHD has a number of systems and programs in place (figure 1)
March 12-18, 2023
Human factors
Most adverse events in health are not due to technical failures. All humans make mistakes and understanding the factors that reduce our ability to perform at our best can in turn assist us to propose solutions on how to reduce risks. Human factors is a science that focuses on understanding human behaviour and how people interact with each another and their environment.
Patient safety culture
A positive safety culture underpins robust reporting of incidents, honest practice review and drives innovation and continuous improvement. NSLHD encourages staff to raise safety issues or question an action that compromises safety, regardless of position or level in the organisation, creating a responsibility centred safety culture for the entire workplace. A just culture is promoted where individuals are treated fairly and not blamed for failures of the system. The focus is on improving the systems that enabled the incident to occur. In this way, we are learning to prevent the same types of incidents from recurring and we make our systems safer.
Speaking up for safety
Staff, patients, families and carers must feel psychologically safe to speak up when there is a concern. Safety is optimised when people are more likely to raise a safety concern by speaking up for safety. The speaking up for Safety program develops staff capability to effectively communicate concerns to colleagues that unintended harm is about to occur.
Figure 1.
Source: NSLHD Clinical Governance Framework 2022-2025
Clinical Governance Standard
MARCH 2023
EDITION 22
NEW RESOURCES: HOSPITAL ACQUIRED COMPLICATIONS Following feedback and discussions with clinical experts and health services from across Australia, the Australian Commission on Safety and Quality in Health Care (ASQHC) has released new FAQs and resources to support the understanding, prevention and reduction of Hospital-Acquired Complications (HACs).
A HAC refers to a patient complication for which clinical strategies may reduce, but not necessarily eliminate, the risk of that complication occurring i.e. the complication may be preventable.
how to use and interpret HACs data a user guide for reviewing clinical variation recommended national goal rates for reducing HACs a searchable list of complication specific clinical care standards, guidelines and literature a feedback survey In addition to the previously available HACs factsheets on the ASQHC's website, these updates include: Data on HACs can be accessed through the quality improvement data system (QIDS) and may be filtered by location (ward, facility, district level), drilled down further by diagnosis type or reported as a trend over time. Visit the QIDS intranet page for more information HACs monitoring and review builds on, and aligns with the NSQHS Standards (Action 1.28 - Variation in clinical practice and health outcomes) and is further supported by the Commission’s recently published User Guide for Reviewing Clinical Variation and Clinical Care Standards.
HUMAN FACTORS: COMPLACENCY
Over the next few months we will be high lighting some of the contributors to Human factors when things go wrong. This month we will take a more detailed look at Complacency. Complacency can occur when a task being undertaken has been performed so many times that it becomes a habit and is considered low-risk or a safe task to do without much thought. Example: This could happen in healthcare situations when you have known a patient for a length of time and have been giving the patient the same medication for a few weeks, the dose of the medication increases but you don’t notice and just continue to deliver what you have always delivered.
The Filthy Fifteen (Gordon DuPont, 1993 / Boeing 2014)
Pressure
Stress
Complacency
Lack of operational integrity
Distraction
Fatigue
Lack of professionalism
Lack of communication
Lack of assertiveness
Lack of Awareness
Not admitting limitations
Lack of knowledge
Lack of resources
Lack of teamwork
Norms
The potential precursors to accidents, incidents or elements that can influence people to make mistakes. The aim of the concept is to focus attention and resources towards reducing and capturing human error. Although these were designed in relation to the airline industry, they can also be applied to the healthcare industry as causes for accidents or incidents.
Clinical Governance Standard
Contact: NSLHD-SQEP@health.nsw.gov.au
MARCH 2023
EDITION 22
Project Spotlight
S.O.S - SAVE OUR SKIN
Providing world-class clinical care where patient safety comes first is a key priority for NSW Health. Royal North Shore Hospital Neonatal Intensive Care Unit's S.O.S Save Our Skin project has improved the safety of vulnerable infants in their care. Neonates are at risk of skin injuries, including extravasation injury secondary to peripheral intravenous cannula (PIVC) infiltration, which can lead to long-term morbidity, including infection, skin loss and scarring (Restieaux et al. 2013, Hackenberg et al. 2021). The project team aimed to make care safer, by reducing PIVC- related extravasation injuries in the NICU by 50 per cent within six months. The team engaged with a number of stakeholders, including parents. Change ideas were tested and successfully embedded into clinical practice, documentation was improved, and a neonatal infiltration scoring system was introduced. The team was able to reduce the incidence of extravasations from 9% to 4.5% (by 3 months), then to 0% (by 6 months) – a 100% reduction – with improvements sustained beyond the initial project. The project has reduced the risk of long-term morbidity from neonatal skin injuries, meeting the Future Health Strategy of delivering safe, high-quality, reliable care for patients in hospitals, and ensuring infants get the best start in life. It also equipped staff with skills and capabilities to be an agile, responsive workforce. The project team were awarded the Patient Safety First Award at the 2022 NSLHD Quality and Improvement Awards. Check out this short video of their project
Transforming the Patient Experience Patient Safety First Delivering Value-Based Integrated Care Supporting our People and Culture Keeping People Healthy Health Research and Digital Innovation Excellence in the Provision of Mental 1. 2. 3. 4. 5. 6. 7. The Northern Sydney Local Health District Quality and Improvement Awards celebrate the outstanding achievements of teams across our health district who introduce change to improve patient outcomes and experience, staff experience and the overall quality of our health service. There are eight award categories:
Health Services Planetary Health
8.
Key dates (2023)
Entries open: 27 Feb - 6 April* Finalists announced: 24 May NSLHD Quality and Improvement Awards Ceremony: 29 June
* please note local sign-off process and deadlines at your facility or service
Visit the Quality awards intranet page to download the entry form and submission guide, view local signoff deadlines, contacts for award coordinators and advisors and other resources
Check out last year's finalist and their projects
Emily Macnaught (Clinical Nurse Consultant and Project lead) accepting the Patient Safety First Award at the 2022 NSLHD Quality and Improvement Awards Ceremony
Contact: NSLHD-Awards@health.nsw.gov.au Catherine Rosario (Clinical Reliability Improvement Facilitator | Quality Awards Coordinator)
How do I start an improvement project? Find out more on the Clinical Governance Quality Improvement Intranet site, Innovation Hub or contact your local quality advisor
Clinical Governance Standard
MARCH 2023
EDITION 22
A key change in the provisions outlined in the Public Health Regulation 2022 - NSW Legislation is the simplification of paperwork required for cremation applications (Part 8 Division 4 Disposal of bodies). A cremation certificate is no longer required. Instead a relevant medical practitioner* needs to provide written advice about the physical risk of cremation of a deceased person. The relevant medical practitioner in this context is (i) a medical practitioner who attended the person immediately before or during the illness terminating in the death of the person or (ii) has relevant knowledge of the dead person’s medical history. As such the Attending Practitioners Cremation Certificate (NH606572) has been superseded by the Cremation Risk Advice (NH700903) form and the NSLHD Death Certification Checklist (NS08634) has been updated to reflect the changes. The Cremation Risk Advice form is available for ordering from STREAM Solutions and the Death Certification Checklist is available for ordering from Design and Print Management. Request forms are located here. * relevant medical practitioner definition: refer to 103 (7) Public Health Regulation 2022 - NSW Legislation ) CREMATION RISK ADVICE AND UPDATED DEATH CERTIFICATION CHECKLIST
Consumer and Patient Experience
Partnering with Consumers Standard
PATIENT REPORTED MEASURES – PROMs and PREMs
The Patient Reported Measures (PRMs) program transitioned into NSLHD Clinical Governance's Consumer and Patient Experience portfolio in early 2023. Along with Central Coast LHD, NSLHD was the first in NSW to integrate the Health Outcomes Patient Experience (HOPE) Platform into the eMR in February 2023. This integration commences ‘Phase 2’ of the State-wide PRMs Program and is anticipated to improve clinician access to PROM survey results. Work will continue on this integration throughout 2023 to further enhance functionality and automation of processes. The NSLHD PRMs team have been selected to present at the Agency for Clinical Innovation (ACI) Patient Reported Measures Research Symposium in May 2023. NSLHD is proud to participate in showcasing to the state this initiative along with the latest research and quality improvement projects that use PRMs to improve healthcare in NSW. Congratulations to Ward 3 at Ryde Hospital, who are the first inpatient service in NSLHD to commence the collection of PROM and PREM surveys. The program was successfully implemented for hip fracture patients on 27 Feb 2023.
For more information visit the PRM Intranet page or contact us on nslhd-prms@health.nsw.gov.au.
LESSONS LEARNED FROM SERIOUS ADVERSE EVENT REVIEWS Did you know that the Clinical Excellence Commission shares findings from serious incidents that have occurred across NSW to aid in reducing preventable risk of a similar event occurring to another patient? The latest lessons from Mental Health and Alcohol and Other Drugs Serious Incident Reviews include the importance of taking a corroborative history prior to discharge from the ED and venous thromboembolism risk assessment for hospitalised patients in Mental Health Inpatient Units. Access via the lessons learned intranet page.
MARCH 2023
EDITION 23
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.
March 2023 QARS Audits (entry links)
NSLHD_03_Aseptic Technique
St 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MVH | MHDA) NSLHD_05_Cognitive Impairment Audit (Delirium) NSLHD_05_Nutrition Audit NSLHD_05_Surgical plume and electrosurgical audit (RNSH | HKH | Ryde )
St 4
St 5
NSLHD_06_Consent Audit (RNSH | MVH | Ryde | HKH )
St 6
NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists (RNSH | HKH | Ryde | MV | MHDA | PACH-HITH)
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 Unregistered Babies Less than 20 weeks Gestation Investigation and Bereavement Care (updated) NSLHD Radiation Management Plan (new) NSLHD Radiation Incident Flowchart (new) Nitrous oxide / Entonox therapy for ADULT patients with acute pain - NSLHD (updated) Antiplatelet therapy in patients with Acute Coronary Syndrome (ACS) - NSLHD (updated) Construction, Renovation and Maintenance - Infection Prevention and Control Management Guideline Diabetes Mellitus: Capillary Blood Ketone Monitoring for Adults in the Inpatient Setting - NSLHD Neonatal Abstinence Syndrome (NAS) Assessment and Management – NSLHD
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 SN:005/23: Potential for error: look-alike medicines presented in blue medicine bottles - issued 06 March 2023 SA:003/23: Encephalitic Flaviviruses (MVEV, JEV, KUNV) - Update for Clinicians - issued 23 February 2023 SN:004/23: Clinician Alert – Foodborne Botulism - issued 22 February 2023 SI:004/23: Potential for error: look-alike HYDROmorphone and morphine sulfate Medsurge® solution for injection - issued 20 February 2023 SN:003/23: Supply disruption: Rapid Fetal Fibronectin (fFN) 10Q cassettes - issued 14 February 2023
For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au
Medication Safety Updates including medication shortages are available on the CEC website.
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