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
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