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.
OCTOBER 2025
EDITION 40
IN THIS EDITION: NSLHD Applied Safety and Quality Program - Applications open to participate in 2026 Gathering of Kindness Week (10-16 November)
MHDA Rights and Responsibilities video Updated Massive Transfusion Protocol (MTP): What You Need to Know
Delivered in partnership with the Clinical Excellence Commission , the year-long Applied Safety and Quality Program is currently the highest-level learning and development offering under the Safety and Quality Essentials Pathway . Gain practical skills in quality improvement and change leadership Receive support and coaching from experienced facilitators and peers CPD and University Credit Showcase your initiative and its impact on service improvement and patient safety. Ready to find out more? Scan the code or visit the Applied Safety and Quality Program hub https://bit.ly/NSLHD-ASQP to View more testimonials and project learnings Download the program information and application form Discover the benefits for Managers in supporting staff to participate Why join?
Erin Spillane (Nurse Unit Manager, Child Youth and Family Health Service) shares her reflections as a past participant: Ready to Lead Change? Apply to join the Applied Safety and Quality Program in 2026! “ From the very first session, participants were inspired by a diverse cohort of passionate professionals—such as nursing, allied health, and management—each bringing unique perspectives and a shared commitment to improving care.” What stood out most? “One of the most valuable aspects of the program has been the confidence it gave me—not only to use improvement methodologies, but to bring those skills back to my team in a meaningful way. This program empowered me to facilitate more effective conversations, identify clinical risks proactively, and create environments where psychological safety and staff wellbeing are priorities. I will walk away from this experience feeling inspired, better equipped and deeply grateful.”
Applications close 14 November Questions? Contact the program coordinators NSLHD-SQEP@health.nsw.gov.au
https://bit.ly/NSLHD-ASQP
Clinical Governance Standard
Erin Spillane with Mark Zacka (Executive Director, Clinical Governance and Patient Experience, NSLHD)-at the Applied Safety and Quality Program Graduation, 12 Feb 2025
OCTOBER 2025
EDITION 40
Gathering of Kindness Week 2025 NSW Health’s Gathering of Kindness 2025 will take place from 10 to 16 November , aligning with World Kindness Day on 13 November. This year’s theme, “One care, many voices – because kindness lives here,” invites us to listen deeply and reflect on how kindness is expressed - in conversations at the bedside, in everyday teamwork, in courageous leadership, and in quiet moments of care. Across the week, Northern Sydney Local Health District (NSLHD) will mark the occasion with a range of activities across its facilities, including: Kindness-themed stalls in hospital foyers Artworks and kindness cards The continuation of 160 Tales of Kindness , a concept started at Prince of Wales Hospital and now in its third year at NSLHD. Use the Compliment Portal to send a Tale of Kindness to a colleague, encouraging reflection on acts of kindness in the workplace.
🎥 Be sure to watch the new Small Acts of Kindness videos, featuring real-life stories from NSW Health staff, volunteers, patients, and families—showing how even the smallest gestures can make a big impact.
Let’s celebrate the voices that shape our care and the kindness that lives in all of us.
MHDA Rights and Responsibilities Mental Health Month is the perfect time to showcase the Mental Health Drug and Alcohol (MHDA) Rights and Responsibilities video , designed for clients/consumers, carers, and families of MHDA services to ensure that their unique health journey has been clearly explained. Demonstrating our commitment to delivering high-quality and safe care that promotes and empowers individuals to be active participants in their recovery journey, strengthens trust between staff and consumers/clients, and builds a culture of respect and collaboration. It is recommended that this video form part of the admission process for clients/consumers and their carers and families. Staff are encouraged to use this video as a foundation for open, supportive conversations about care.
NSLHD Mental Health Drug and Alcohol Your rights and responsibilities You Tube | 4 mins
OCTOBER 2025
EDITION 40
Updated Massive Transfusion Protocol (MTP): What You Need to Know
The Massive Transfusion Protocol (MTP) has been updated district-wide following extensive consultation and experience in managing critically bleeding patients. These changes aim to improve patient outcomes and reinforce the importance of clear clinical communication at this critical stage of care.
Key Changes: 1. Activation Process Dial 2222 and request: “Activate an MTP”. Switchboard will ask for: Patient size (Adult / Paediatric / Neonate) Location (Ward and Bed Number)
Contact details, name, and designation for the Blood Coordinator In non-critical care areas, activate a Code Blue before MTP.
2. Introduction of the Blood Coordinator A clinician (nurse, midwife, or doctor) allocated by the treating doctor. Acts as the key link between the clinical team and the Transfusion Laboratory (Blood Bank). Communicates patient movement within the hospital facility to the Blood Bank. 3. Blood Product Packs This is for the purpose of providing component therapy that reflects the closest representation of ‘whole blood’. Pack 1 : 3 Units RBC, 3 Units FFP or Extended Life Plasma, 10 Units Cryoprecipitate Pack 2: 3 Units RBC, 3 Units FFP or Extended Life Plasma, 1 Unit Platelets A Haematology referral should be made after the receipt of Pack 2. 4. “Stand Down” Communication When it’s time to stop the continual provision of Pack 1 and Pack 2, the Blood Coordinator will dial 2222 and request: “MTP Stand Down”. These updates are designed to support clinical teams and the Transfusion Laboratory in delivering timely, coordinated care for patients experiencing massive bleeding. For further information, visit the NSLHD Blood Management Portal: Critical Bleeding intranet page Contact for inquiries: Alexandra.Cook@health.nsw.gov.au (Patient Blood Management CNC RNSH)
Blood Management Standard
OCTOBER 2025
EDITION 40
NSLHD CLINICAL AUDIT SCHEDULE
Clinical Governance Standard 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 2025 - 2026 NSLHD Clinical Audit Schedule from the Clinical Audit Schedule Intranet page Clinical audits required to be completed this month are listed below.
October QARS Audits (direct links available from Clinical Audit Intranet page)
NSLHD_01_Clinical Documentation – Nursing V2 NSLHD_01_Clinical Documentation Audit -Allied Health NSLHD_01_Clinical Documentation – Medical Officers V2 NSLHD_01_Clinical Documentation - Emergency Department Urgent Care Centre NSLHD_1_Maternity_Safe Sleeping for Babies NSLHD_03_Infection Prevention Control Program compliance NSLHD_03_Transmission Based Precautions V2 NSLHD_04_Prescription Pad - Quality of Prescribing Version 2 NSLHD_04_ Prescription Pad: Storage and handling NSLHD_4_VTE Prevention for admitted patients NSLHD_05_Nutrition Care Audit - Adults and Paediatric patients) NSLHD_05_Post Partum Haemorrhage (PPH) Audit
Standard 1
Standard 3
Standard 4
Standard 5
NSLHD_07_ Blood Product Transfusion Documentation V3
Standard 7
NSLHD_08_MONTHLY_Resuscitation trolley/backpack & Resuscitaire equipment audit
Standard 8
POLICIES, PROCEDURES AND GUIDELINES Refer to the PPG Weekly updates (PPG Resource hub) to access the most up-to-date list of PPGs For any queries relating to policy, procedure and guideline development contact NSLHD-Policies@health.nsw.gov.au
NSLHD – Recently Published Policies, Procedures, Guidelines and Standing Orders
Expedited Specialist Pathway for Psychiatrists – MHDA NSLHD - Procedure GradStart Workforce Guidelines NSLHD - Guideline Medicinal Leech Therapy and Care - RNSH_Procedure Penicillin Allergy Assessment and Direct Oral Challenge Procedure (Adults) - RNSH_Procedure Standing Order Development, Review and Approval Process - NSLHD_Procedure Ketamine Infusion for Pain Management_Procedure Newborn Resuscitation Preparation in Level 4 Theatres, ASB - RNSH_Procedure Patient Controlled Analgesia (PCA) NSLHD_Procedure Nebulised Epoprostenol (Prostacyclin) for Hypoxic Respiratory Failure- NSLHD_Procedure Safety Notifications and Recalls Procedure
SAFETY ALERTS New, updated and recently published
Medication Safety Updates including medication shortages are available on the CEC website.
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