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.
MAY 2025
EDITION 38
IN THIS EDITION: NSLHD Patient Safety Culture Survey: 3 - 17 June What Matters to you Day - 5 June Comfort Observation and Symptom Assessment (COSA) Chart on eMR - 27 May Clonazepam Oral Liquid: Avoiding Dosing Confusion How the Results will be used. The results of this survey will be used to identify areas where we can improve patient safety. Results will be compiled to identify how NSLHD is performing across 10 safety and quality domains, including communications about error, organisational learning, clinical handovers and information exchange. Feedback will then be provided at team, facility and district levels to inform targeted strategies for the continual improvement of our patient safety culture.
TELL US ABOUT PATIENT SAFETY WHERE YOU WORK!
NSLHD Patient Safety Culture Survey NSLHD is pleased to invite staff to participate in the Patient Safety Culture Survey (PSCS) from Tuesday, 3 June to Tuesday, 17 June . This survey is open to all staff members and aims to gather your valuable insights on how patient safety and quality is managed within your specific team/unit. Why Your Input Matters Patient safety is central to all our work in healthcare. Staff are often the first to recognise safety issues. Sharing your experiences can help to identify what needs to improve, as well as what is currently working well. What to Expect The survey will ask about your perceptions and experiences at work on topics such as leadership, team interactions, communication and reporting of safety incidents. These questions are linked to the National Safety and Quality Health Service (NSQHS) Standards and other district priority initiatives. From 9am on Tuesday 3 June , you will receive an email sent from Insync via surveys@insync.com.au. The survey will also be accessible via QR code, your work email address or at this link. The survey will take approximately 15 minutes to complete, and your responses will be entirely anonymous.
Incentives for Participation Teams with 100 per cent or ‘very high’
completion rates will be entered into a draw across NSLHD for the chance to win one of twelve $1,000 cash prizes. The prize can be used by your team to purchase resources for your area or to support staff wellbeing. Please encourage your colleagues to complete the survey during team meetings.
Thank you for your participation and commitment to improving patient safety.
For further information contact: Lauren.Nowacka@health.nsw.gov.au
Clinical Governance Standard
Northern Sydney Local Health District
What Matters to You Day ONLINE EVENT Thursday, June 5
12:00 - 1:00pm
Meet the NSLHD Patient Reported Measures (PRMs) Team
Learn how Patient Reported Outcome Measures are being used to help identify what matters to patients
Hear some of the early findings and consumer perspectives from an NHMRC funded research study 'PROM-PATH'
Online via Microsoft Teams: Click here on the day to join this event
Click to Join
Speaker
Speaker
Speaker Jessica Nikolovski, Research Associate, University of Sydney
Thelma De Lisser Howarth, Consumer and Patient Experience Manager
Marg Fagan, Consumer Advisor NSLHD
Contact: NSLHD-PRMs@health.nsw.gov.au
MAY 2025
EDITION 38
Cerner eMR BTFv5 Enhancement: Comfort Observation and Symptom Assessment (COSA) Chart
From 27 May 2025 , NSLHD will transition from the paper-based Care of the Dying to the Cerner eMR Between The Flags (BTF) Comfort Observation and Symptom Assessment (COSA) Chart . This state-endorsed chart is designed to support consistent, high-quality documentation and symptom monitoring for ADULT patients receiving end-of-life care. The eMR build is part of the Clinical Excellence Commission’s (CEC) Initiating Last Days of Life Management Plan and aligns with NSQHS Standard 5 – Comprehensive Care and and Standard 6 – Communicating for Safety . Its implementation positions NSLHD in line with other local health districts and supports the transition to the Single Digital Patient Record. When to use the COSA chart he Use the COSA chart when the treating medical team has formally documented a change in the patient’s care goals—from active treatment to supportive end-of-life care—and SAGO Adult observations are no longer required. Either medical officers or nursing staff can switch the patient’s BTF chart from SAGO Adult to COSA. COSA defaults to 4-hourly observations. Nursing staff will document comfort observations and symptom assessments directly in the eMR COSA Chart. Once COSA is activated, comfort observations will no longer be documented in iView. During downtime The downtime form will be the CEC paper COSA Chart, which can be ordered as instructed below. The COSA Quick Reference Guide and COSA Demonstration Video can be access via he eMR User Guides And Support Documentation > Powerchart General
For further information contact : kellie.cooper@health.nsw.gov.au (Advance Care Planning Facilitator)
Comprehensive Care Standard
Communicating for Safety Standard
Clonazepam Oral Liquid: Avoiding Dosing Confusion
The April 2025 edition of Australian Prescriber features an important article titled: “Medicinal mishap: Clonazepam oral liquid—confusion between drops, milligrams and millilitres.” Authored by Joey Chan (Senior Pharmacist) and Dr Abigail E Franklin (Palliative Medicine Physician) of the Adolescent and Young Adult Hospice, the article highlights serious medication errors linked to the prescribing and administration of clonazepam oral liquid. Unlike most oral liquid medicines, clonazepam oral liquid must be prescribed and measured in drops—not millilitres. This distinction is critical, as confusion between drops, milligrams, and millilitres has led to significant dosing errors, with the potential for harmful adverse effects. In response, SA Health and the Victorian Therapeutics Advisory Group (VicTAG) have issued safety alerts urging health professionals to: Prescribe doses in number of drops, with the corresponding milligram (mg) amount in brackets. Measure and administer doses in drops, not millilitres. The NSW Clinical Excellence Commission is also developing an advisory to support safe use of clonazepam oral liquid across the state.
Healthcare professionals are strongly encouraged to remain vigilant and ensure clear, consistent communication when prescribing or administering clonazepam oral liquid to avoid preventable harm.
🔗 Read the full article here
Medication Safety Standard
MAY 2025
EDITION 38
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.
May and June QARS Audits (direct links available from Clinical Audit Intranet page)
NSLHD_01_Clinical Documentation – Nursing V2 NSLHD_01_Clinical Documentation – ALLIED HEALTH
NSLHD_01_Clinical Documentation - Emergency Department & Urgent Care NSLHD_01_Clinical Documentation - Health Information Services (HIS) V2
Standard 1
NSLHD_01_Clinical Documentation – Medical Officers V2 NSLHD_01_Clinical Documentation Audit_ VCS Version 3 NSLHD_1_Maternity_Safe Sleeping for Babies
NSLHD_03_Peripheral Intravenous Cannula (PIVC) Insertion and Management - V2
Standard 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit NSLHD_4_VTE Prevention for admitted patients 2025 Vaccine Management and Storage Audit in QARS
Standard 4
NSLHD_06_Clinical Handover – Nursing and Midwifery BEDSIDE Shift-to-Shift V2 NSLHD_06_Clinical Handover -all Clinical Disciplines
Standard 6
NSLHD_07_Patient Blood Management (Perioperative) 2025
Standard 7
NLSHD_08_MONTHLY_Resuscitation trolley/backpack & Resuscitaire equipment audit -V2 (Audit available from 1 June – 30 June 2025)
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
Haemodialysis: Fluid Assessment - NSLHD Guideline Intra-operative Topical Rifampicin Use During Aortic Surgery - Medication Protocol Cord Blood Banking - (PD2025_016) Ministry of Health Policy Directive Fetal Heart Rate Monitoring (GL2025_004) - Ministry of Health Guideline Cyber Security Procedure - NSLHD Procedure Neonatal Resuscitation (GL2025_003) - Ministry of Health Guideline
SAFETY ALERTS New, updated and recently published
Medication Safety Updates including medication shortages are available on the CEC website.
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