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
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