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.
SEPTEMBER 2022
EDITION 18
NSLHD APPLIED SAFETY AND QUALITY PROGRAM 2023
IN THIS EDITION:
NSLHD Applied Safety and Quality Program Improvement Science Workshops National Clinical Trials Governance Framework World Patient Safety Day - Medication without Harm World Sepsis Day
Do you want to make a difference and improve the quality of your workplace to deliver the best healthcare for our patients and consumers? The Clinical Excellence Commission has partnered with NSLHD to deliver the Applied Safety and Quality Program . Participants of the 12-month program will learn to apply safety and quality tools, methods and behaviours to champion, role model, support and lead safety and quality in their local workplace. Across NSW, six other LHDs have officially launched the program, with over 100 people currently participating. NSLHD will have its first cohort take part in this state- wide program in early 2023. The Applied Safety and Quality Program supports the practical application of patient safety, improvement science and facilitation skills in the local workplace including support to undertake a quality improvement project. The program includes 8 lab (workshop) days and supported experiential learning over 12 months to build Adept level capability in safety and quality. The program is one of the offerings under the Safety and Quality Essentials Pathway and is mapped to the Adept level of the Healthcare Safety and Quality Capabilities set. Current and aspiring leaders in NSLHD are invited to express their interest in joining the first cohort of the new NSLHD Applied Safety and Quality Program in 2023. Applications are being accepted till the close of business Monday, 17 October 2022. Download the application to find out more.
What did you think of this issue? Give us your feedback.
Clinical Governance Standard
"I was surprised at how relevant all the sessions were to my role and I took so much away from every session." - Applied Safety and Quality Program participant (External LHD) Contact: Cathy.Vinters@health.nsw.gov.au or Catherine.Rosario@health.nsw.gov.au (Clinical Reliability Improvement Facilitators, NSLHD Clinical Governance) or your local Clinical Governance / Quality Manager
SEPTEMBER 2022
EDITION 18
Ever wanted to improve an area of your work but don't know where to start? The final Improvement Science workshop for the year is taking place at Ryde Hospital on 19 October 2022 and is open to all staff across the district who have an interest in improving the safety and quality of their local service and would like to find out how to do it. Participants will expand their knowledge and be equipped with the tools and skills to apply the Improvement Science methodology in projects that improve the safety, quality and patient/consumer experience of their service. This one-day workshop is one of the training offerings under the Safety and Quality Essentials Pathway mapped to the intermediate level of the Healthcare Safety and Quality Capabilities set Wednesday, 19 October 2022. 8.30am – 4.00pm Ryde Hospital, ELCA IMPROVEMENT SCIENCE WORKSHOP Contact: Cathy.Vinters@health.nsw.gov.au or Catherine.Rosario@health.nsw.gov.au (Clinical Reliability Improvement Facilitators, NSLHD Clinical Governance) Spaces are limited. Don't miss out! Book your place on My Health Learning (MHL) using course code 42956746.
Feedback from previous participants after attending the most recent workshop.
100% would recommend the workshop to colleagues.
100% were confident or very confident in their knowledge of the quality improvement tools and methodology post workshop.
Lots of extremely useful information for my role. I can use what was presented here today to improve my skills and knowledge.
So helpful and great workshop. The presenters were very clear with great facilitation.
NATIONAL CLINICAL TRIALS GOVERNANCE FRAMEWORK
We welcome the appointment of Dr Sadia Mahboob as Quality Manager (Clinical Trials Accreditation, NSLHD), to support the implementation of the CT Governance Framework across NSLHD. Based in the NSLHD Research Hub team, Sadia will work closely with the NSLHD Research Strategy Manager, the National Safety and Quality Health Service Accreditation Manager, the Facilities/Services’ Quality Managers and our clinical trials groups across the district. For more information contact Sadia.Mahboob@health.nsw.gov.au
The Australian Commission on Safety and Quality in Healthcare (ACSQHC) launched the National Clinical Trials Governance Framework in May 2022. The National Clinical Trials Governance Framework (CT Governance Framework) is ‘ the first step towards a nationally consistent approach to the accreditation of health services for the conduct of clinical trials .' The National Clinical Trials Governance Framework builds on the National Model Clinical Governance Framework and the National Safety and Quality Health Service (NSQHS) Standards . Implementation of the Governance Framework will commence from 2023, in alignment with accreditation assessments of health service organisations to the NSQHS Standards. To assist with implementation of the CT Governance Framework, the ACSQHC is offering 1.5 hour workshops as follows;
13 October 2022 from 12:00pm to 1:30pm 10 October 2022 from 2:30pm to 3:30pm 8 December 2022 from 10:00am to 11:30am,
Dr Sadia Mahboob
Please refer to the website to register. Resources are also available on this website.
SEPTEMBER 2022
EDITION 18
MEDICATION WITHOUT HARM The World Health Organization (WHO) World Patient Safety Day takes place on 17 September every year. The theme for 2022 is Medication Safety, building on the WHO Global Patient Safety Challenge -
Medication without Harm. The key action areas are:
Monitoring polypharmacy and responding to inappropriate polypharmacy 1. 3. Improving medication safety at transitions of care 2. Reducing harm from high-risk medicines
Clinicians are encouraged to:
Keep your skills in safe medication practices up to date Engage patients through shared decision-making using tools such as the 5 Moments for Medication Safety and implement actions related to the Know. Check. Ask. campaign Provide clear and full medication-related information to all members of the clinical team throughout the process of care Report medication safety incidents, and share and apply lessons learned with your team and patients when possible Be mindful of situations where the risk from medications is high and ensure safety measures are followed Mentor new members of your team on safe medication systems and practices Contact your managers/team leads and take part in clinical auditing for medication safety.
Resources:
Medication without harm – WHO Global Patient Safety Challenge: Australia's response (ACSQHC) Medication Safety - NSLHD Medication Safety - Clinical Excellence Commission View exemplar projects from around Australia
Medication Without Harm - World Patient Safety Day 2022 video (1 min) (World Health Organization)
Medication Safety Standard
SEPTEMBER 2022
EDITION 18
WORLD SEPSIS DAY - 13 SEPTEMBER 2022
The National Sepsis Clinical Care Standard (ACSQHC)- outlines optimal care for patients in hospitals with suspected sepsis – from the onset of signs and symptoms through to discharge from the hospital and follow- up care. The Information for Clinicians- Sepsis Clinical Care Standard describes what each statement means for clinicians involved in sepsis care. It outlines key considerations for clinicians in regard to equity and cultural safety. Spotlight on Sepsis video series - short videos covering the perspective of Consumers, Clinicians and Aboriginal and Torres Strait Islander people Guidelines such as Sepsis Kills Adult Antibiotic Guideline (NSLHD) and Newborn Antibiotic Guideline for early and late-onset Sepsis during a birth episode of care (NSLHD) - Access PROMPT for a full list of all relevant policies, procedures or guidelines Each year more than 8,700 Australians die from sepsis[i], a condition that is triggered by an infection and can turn into a deadly disease if undetected. People with sepsis can deteriorate quickly, and the early signs and symptoms can be hard to recognise. It is crucial to ask, ‘Could it be sepsis?’. Visit the Sepsis Intranet page -NSLHD to access links to resources including:
SEPTEMBER 2022
EDITION 18
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 and next month are listed below.
September 2022 QARS Audits (entry links)
NSLHD_03_Aseptic Technique NSLHD_03_Perioperative sharps management_2022 (RNSH ASB OT | RNSH Ambulatory care | HKH OT | Ryde OT / Periop)
St 3
NSLHD_4_Monthly Accountable Drug (S4D_S8) Register Audit (RNSH | HKH | Ryde | MV | MHDA)
St 4
NSLHD_06_Clinical Handover - all Clinical Disciplines NSLHD_06_Handover; Nursing Shift to Shift 2021 (RNSH | HKH | Ryde | MV) MHDA_Clinical Handover PACH Communicating for Safety Audit Tool NSLHD_06_Consent Audit (RNSH | HKH | Ryde | MV) NLSHD_08_Monthly inspection for resuscitation trolley/ Resuscitaire equipment checklists
St 6
NSLHD_8_Resuscitaire Checklist NSLHD_8_MHDA_Engagement and Observation Audit_2022 (RNSH | HKH | Ryde | MV | MHDA | PACH)
St 8
POLICIES, PROCEDURES AND GUIDELINES New, updated and recently published district-wide PPGs.
Clinical Governance Standard
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
Medicated Dressing Policy - NSLHD NSLHD Capital Framework Sudden Unexpected Death in Infancy (SUDI) Management 1800 Mental Health Line (1800 MHL) General Practitioner Electronic Referral Procedure Tracheostomy Management Procedures in Adults eMR Downtime Policy NSLHD eMR Downtime Procedure NSLHD Injury Management and Workers Compensation - NSLHD
SAFETY ALERTS New, updated and recently published
Clinical Governance Standard
- Issued 1 September2022
SA:005/22 Criticaldisruptionto supply– tenecteplase(Metalyse®)injection- UPDATED SN:011/22 Strongopioidsdetectedin counterfeit‘Kalma’tablets - Issued26 August2022 SI:006/22 Unregisteredbenzodiazepinesandcounterfeitalprazolamproductsin NSW
- Issued1 August2022
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 For more information, contact: NSLHD-SafetyAlert@health.nsw.gov.au Medication Safety Updates Medication Safety Updates including medication shortages are available on the CEC website. A recent update that is available includes the Drug Guideline – Use of molnupiravir capsules for COVID-19 (Version 1.1, September 2022).
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