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TRANSCRIPT
Building foundations to support patient safety
Sentinel event program
annual report 2009–10
Building foundations to support patient safety
Sentinel event program annual report
2009–10
Sentinel event program annual report 2009–10
If you would like to receive this publication in an accessible format, please phone 03 9096 7201
using the National Relay Service 13 3677 if required, or email [email protected]
This document is also available in PDF format on the internet at www.health.vic.gov.au/clinrisk
Published by Quality, Safety and Patient Experience Branch, Victorian Government
Department of Health, Melbourne, Victoria
© Copyright, State of Victoria, Department of Health, 2010
This publication is copyright, no part may be reproduced by any process except
in accordance with the provisions of the Copyright Act 1968.
Authorised by the State Government of Victoria, 50 Lonsdale Street, Melbourne.
Printed on sustainable paper by On-Demand, 323 Williamstown Road, Port Melbourne 3207.
December 2010 (1012012)
Acknowledgements
The Department of Health thanks Victoria’s public health services, hospitals and participating private
facilities for their ongoing contribution to the sentinel event program.
The department wish to acknowledge the consultative councils and expert advisory groups that
work closely with the department to provide recommendations to health services on system issues.
The department also acknowledges the patients and their carers who have experienced adverse
patient outcomes.
Foreword
Delivering a high-quality health system in Victoria is a major priority for the government.
To ensure the system is safe, it is important to review and examine clinical incidents where
things don’t go as planned, and in particular those events deemed to be sentinel.
Investigation of clinical incidents identifi es where the breakdowns in the health system occur,
and allows health services to identify these risks and develop ways to reduce or remove the risk
where possible.
The Department of Health works together with health services, clinicians and consumers to promote
a culture of reporting when things go wrong. It is only when we are aware of something not working
that we can act to change this.
This is the eighth annual public report of the sentinel event program and it presents information
on the 57 sentinel events reported within Victorian health services during 2009–10.
The focus of the program remains on lessons learnt in order to prevent similar sentinel events in the
future, and will evolve in 2010–11 to incorporate a broader report on patient safety and all reported
clinical incidents within our health system.
Hon David Davis MLC
Minister for Health
Sentinel event program annual report 2009–10
Contents
Summary 1
Sentinel event data 3
Themes in 2009–10 13
Working together to enhance patient safety 15
Consumer participation 17
Clinical effectiveness 21
Effective workforce 25
Risk management 27
Glossary 33
Appendices 33
Appendix 1: Incident severity rating (ISR) 33
Appendix 2: Incident management process 36
Appendix 3: Source data 37
Clinical governance compliance checklist 41
Sentinel event program annual report 2009–10
1
The Department of Health (the department) is responsible for the provision of health services within
Victoria and is committed to improving the quality of these services. Review of incidents and near
miss events plays an important part in this, particularly those events deemed to result in harm
or death. In-depth investigation of these events identifi es breakdowns in the often complex health
system and allows health services to identify risk and develop ways to reduce or eliminate the risk
of reoccurrence.
In 2009–10 the department was notifi ed of 65 potential sentinel events. Eight events were
withdrawn either because they resulted from known complications of the patient’s condition
or required procedure, or because no system or process issues could be identifi ed. Therefore
57 actual sentinel events are included and analysed in this report.
In February 2010 the department began a phased 12-month rollout of the Victorian health incident
management system (VHIMS). This standardised data collection for clinical incidents provides the
department with a mechanism to analyse not only rare and potentially fatal events that are sentinel
in nature, but also the precursor for identifying system issues for less serious events.
This annual report will evolve to include all reported clinical incidents and patient safety issues and
initiatives as we progress the implementation of the VHIMS.
Snapshot of the Victorian health system
The Victorian health system is a complex and busy environment.
In the 2009–10 reporting period, the Victorian Government dedicated an estimated
$12,335 million1 to health care, employed around 74,4132 EFT (equivalent full-time) staff,
managed approximately 1.5 million1 admissions to public health facilities, and performed
more than 273,7293 surgical procedures.
1 Department of Health 2010, Your hospitals: a report on Victoria’s public hospitals July 2009 to June 2010, State Government
of Victoria, Melbourne.
2 Department of Health 2010 Workforce minimum dataset (excludes denominational and Mildura Hospital), State Government
of Victoria, Melbourne.
3 Department of Health, 2010 Victorian admitted episodes dataset, State Government of Victoria, Melbourne.
Summary
2
Sentinel event program annual report 2009–10
3
In the 2009–10 fi nancial period, 57 sentinel events were reported by Victorian public health facilities.
This number represents a decrease compared to previous years. While fewer events were reported,
overall trends remain consistent and the number represents a low incidence rate considering
Victorian public health facilities throughput and activity for the 2009–10 period. Figure 1 highlights
the reported sentinel event classifi cations expressed as a percentage.
The total number of events reported to the sentinel event program (n=57) is the lowest since the
program began in 2002–03. It is diffi cult to determine the exact reasoning as to why this fi gure
continues to decline. Generally where events are reported voluntarily, it is assumed that the number
of events reported would rise over time with improved identifi cation, reporting and confi dence in the
system. There has been considerable investment by Victoria in quality and safety throughout the last
decade by Government and by individual health services. This decline in the total number of reported
events may be refl ective of the Victorian health system developing as a mature learning culture.
Figure 1: Reported events by classifi cation as a percentage of total (n=57)
2009–10
The development of a patient-safety culture is critical to a successful clinical risk management
program. To successfully achieve quality patient care this requires individual health services, and the
department, to become learning organisations. In such organisations, staff are genuinely encouraged
to raise quality and safety issues with anyone in authority, and these issues are responded to quickly.
Responsibility and ownership for patient safety cannot be delegated. All stakeholders including
frontline staff and senior executives are actively involved in analysing adverse events and determining
action to minimise reoccurrence of similar events in the future.
Sentinel event data
4
Sentinel event program annual report 2009–10
A total of nine sentinel event classifi cations are reported in Victoria, eight are national classifi cations
and one is unique to Victoria. Figure 2 illustrates the eight national sentinel event classifi cations
reported since the Victorian program began in 2002.
Trend analysis on historical sentinel event data spanning 2002–2009 has not identifi ed any signifi cant
emerging trends as illustrated in Figure 2 other than a spike in procedures involving the wrong
patient or body part in 2007–08. In 2009 the Australian Commission on Safety and Quality in Health
Care (the commission) amended the defi nition of this sentinel event to specify only events ‘resulting
in death or major permanent loss of function’. Since the revised defi nition, Victoria has not received
any reports of events under this classifi cation.
Figure 2: Reported events by classifi cation 2002–10
* Excludes ‘other catastrophic’ classifi cation which is specifi c to Victoria
* Source data is available in appendix three
The ninth classifi cation, ‘other catastrophic event’, is unique to Victoria. Events reported in this
classifi cation include signifi cant near-miss events and cases where health services have identifi ed
an unexpected patient outcome unrelated to the patient’s condition that warrants review of causation
and potential contributing factors.
5
The 2002–10 data relating to the ‘other catastrophic event’ classifi cation is illustrated in two
distinct groups: complications of management in Figure 3a and other reported events in Figure 3b.
This separation best illustrates the emergent trends over eight years.
It is pleasing to see both groups demonstrate a predominantly downward trend.
The rebound spike in 2008–09 (n=21) of Figure 3b coincides with the commission’s defi nition
change for procedures on the wrong patient or body part. All procedures reported under the
previous defi nition that had not resulted in death or permanent loss, were moved to the ‘other
catastrophic’ classifi cation.
Figure 3a: Reported events classifi ed as ‘other catastrophic’ –
complication of management 2002–10
* Source data is available in appendix 3
6
Sentinel event program annual report 2009–10
Figure 3b: Reported events classifi ed as ‘other catastrophic events’ –
other reported events 2002–10
* Source data is available in appendix 3
Victoria continually seeks to proactively manage clinical incidents and to understand the valuable
lessons that can be learnt from both actual incidents and near miss events.
A key component of VHIMS is the methodology to determine the incident severity rating (ISR).
This methodology provides a standardised quantifi er of harm, or degree of impact, for actual
patient outcome as a result of an incident, as opposed to the popular risk-rating methodology
that is more subjective.
ISR is a process of classifying incidents and provides a standardised approach to the level
of investigation and expected organisational response. The severity is divided into four levels
ranging from one being the highest level of harm, through to four (near miss). ISR is determined
by an algorithm that incorporates three factors: degree of impact, level of care and treatment
required as a result of the incident. Defi nitions of the individual ISR factors are detailed in Appendix 1.
7
We have used the ISR to analyse the 2009–10 sentinel event data as outlined in Figure 4. Not
surprisingly, ISR 1 events were the highest category for the sentinel event classifi cations. Notably,
the classifi cation ‘other catastrophic event’ was the most frequently ranked classifi cation in this
grouping together with suicide. If we were to concentrate only on the eight national sentinel event
classifi cations, this picture would be quite different.
Considering the maturity of the Victorian sentinel event program and the impact VHIMS will have
in monitoring multi-severity level incidents, the department’s sentinel event program will focus on
high degree of impact incidents, that is ISR 1 incidents in the future. Victoria will continue to report
sentinel event data nationally as required.
Figure 4: Reported events by severity rating and classifi cation (n=57) 2009–10
ISR 1: Severe (including death) ISR 2: Moderate ISR 3: Mild ISR 4: No harm (includes near miss)
8
Sentinel event program annual report 2009–10
Figure 5: Reported events by degree of impact (n=57) 2009–10
9
Figure 6: Reported events by level of care (n=57) 2009–10
*Not applicable due to death of patient
10
Sentinel event program annual report 2009–10
Figure 7: Reported events by treatment required (n=57) 2009–10
* Not applicable due to death of patient
Not all ISR 1 incidents will be the equivalent of a sentinel event. If, on initial review by the health
service, the incident outcome was directly related to system or process issues, a root cause analysis
(RCA) should be undertaken to determine causation and indentify contributing factors.
On the other hand, if the initial review identifi es that major contributing factors were related to the
patient’s illness or management phase of their chronic illness, then an RCA is not warranted. These
cases may be reviewed using an in-depth case review to determine if any system issues contributed
to the patient’s outcome.
All incidents, irrespective of their ISR rating, should be reviewed in order to identify opportunities
for system improvement. The incident management process that underpins VHIMS is outlined
in Appendix 2. This process map illustrates how a single incident reported by frontline staff can
result in service improvement.
The department expects all public-funded health services to report clinical incidents through
VHIMS. This expectation will be supported by the implementation of the Victorian health incident
management policy in 2011.
11
Open disclosure
Open disclosure is the process of open communication with the patient or their carer following
an adverse event.
It’s important that patients and their carers are informed when an unexpected outcome
is identifi ed. In accordance with the Victorian Charter of Human Rights and Responsibilities
Act 2006 (Vic), public entities (including public health services) have a legal obligation to discuss
adverse events with the affected patient or their carer.
In 2002 the former Australian Council for Safety and Quality in Health Care (now the commission)
developed the National Standard on Open Disclosure. This was endorsed at the Australian Health
Ministers Conference in July 2003 and reviewed in 2008.
The standard outlines a clear and consistent process which includes:
• an apology or expression of regret
• a factual explanation of what occurred, including actual and potential consequences, and
• the steps being taken to manage the event and prevent its recurrence.
Open disclosure is closely linked to the incident management process, and is incorporated into the
clinical governance policy framework. Guidelines and implementation toolkits were developed in
2008, and in 2009 the department conducted a series of workshops designed to up-skill staff and
provide some practical resources to manage the disclosure process.
An open disclosure e-learning package has been developed to build on this work and previous
toolkits. This online package can be accessed at: http://www.health.vic.gov.au/clinrisk/opendisc.htm
12
Sentinel event program annual report 2009–10
13
During 2009–10, a total of 301 contributing factors were identifi ed. An analysis of these factors
underpins the health services’ development of a risk reduction action plan to minimise similar
events reoccurring. Often events involve more than one contributing factor therefore the number
of contributing factors can be greater than the number of events.
While a range of contributing factors were identifi ed, analysis of the data shows that procedures
and guidelines, human resources/staff issues and communication were the most consistently
reported contributing factors identifi ed with sentinel events for 2009–10. This continues the
trend from previous years as outlined in Figure 8 and the fi nding is consistent with national and
international trends.4 5 6
Figure 8: Reported events by contributing factors expressed
as a percentage 2002–10
*Source data is available in appendix 3
4 World Health Organization 2008, Summary of the evidence on patient safety: implications for research World Health
Organization, Geneva.
5 Clinical Excellence Commission and NSW Department of Health 2010, Clinical Incident Management in the NSW Public
Health System 2009, Government of New South Wales, Sydney.
6 WA Department of Health 2009, WA sentinel event report 2008–09, Government of Western Australia, Perth.
Themes in 2009–10
14
Sentinel event program annual report 2009–10
Contributing factors may include many components:
• the procedures and guidelines grouping is made up of clinical guidelines, behavioural and
physical assessment, physical patient observation process, patient or site identifi cation and
coordination of care
• human resources is a collective term that represents staff allocation, training, supervision,
appraisals and staff recruitment
• communication represents communication between staff, between staff and patient or family,
and translation and cultural and linguistic diversity issues
• physical environment represents environmental distractions and security or design issues, and
• facilities management represents transportation and inter-hospital issues.
Comprehending the complexities of the Victorian healthcare system is fundamental for the
department in targeting effective analysis and improvement strategies. The activity of direct
patient care is often referred to as the ‘pointy end’ of the system. The ‘blunt end’ of the system
is represented by the broader management and organisational aspects involved in supporting
the healthcare system. It includes a wide variety of factors such as policies and guidelines, health
information systems, staffi ng patterns and environmental factors. To understand why an adverse
event occurs at the pointy end, it is necessary to examine and analyse the contributing factors
at the blunt end.7
7 Canadian Patient Safety Institute 2006, Canadian root cause analysis framework, Canadian Patient Safety Institute,
Edmonton.
15
Quality of health care is increasingly recognised as one of the most signifi cant issues facing health
systems. The department is committed to ensuring quality health care within Victorian hospitals.
A key action for building capacity to facilitate quality health care is for organisations to work in
partnership. The department supports building effective partnerships within health organisations,
across health services and with other key stakeholders at state and national levels.
Initiatives highlighting these partnerships have been included throughout this report.
Clinical governance framework
Clinical governance is defi ned as: ‘the system by which the governing body, managers, clinicians
and staff share responsibility and accountability for the quality of care, continuously improving,
minimising risks, and fostering an environment of excellence in care for consumers, patients
and residents.’8
The Victorian clinical governance policy framework (the framework) was developed in 2008
to guide health services to implement a framework or review and further develop existing
frameworks to ensure quality and safety mechanisms are monitored and reviewed.
8 Department of Health 2008 Victorian clinical governance policy framework, State Government of Victoria, Melbourne.
http://www.health.vic.gov.au/clinrisk/publications/clinical_gov_policy.htm
Working together to enhance patient safety
16
Sentinel event program annual report 2009–10
Domains of quality and safety
The framework is underpinned by the four domains of quality and safety:
• consumer participation
• clinical effectiveness
• risk management
• effective workforce.
These domains provide the structure for activities and processes to enhance the delivery
of clinical care.
This report incorporates a clinical governance compliance checklist (see appendix) linking the
domains of quality and safety with the Australian Council on Healthcare Standards (ACHS) EQuIP
4 mandatory criteria. Health services can use this checklist to ensure their strategies are congruent
with the framework and the relevant ACHS mandatory criteria. The checklist has been designed
as a tear-out section for health services looking to use the resource as a periodic compliance tool
for the framework.
17
Consumer participation should occur at many levels of the organisation, through activities such
as community consultation and consumer partnership on governance and management committees,
and within improvement initiatives or clinical risk management activities. The department expects
strategies should be in place to ensure:
• consumers are empowered to participate in their care
• there is clear, open and respectful communication between consumers at all levels
of the health system
• services respond to the diverse needs of consumers and the community with humanity
• rights and responsibilities of patients are promoted to community, consumers, carers,
clinicians and other health service staff.
Case study
An elderly patient accompanied by their son presented to an emergency department (ED). The
patient took a seat in the waiting room whilst the son proceeded to register the patient.
During patient registration the receptionist requested the patient’s name and date of birth (DOB).
The son was unable to confi rm the DOB therefore the receptionist searched the system without
confi rming the spelling of the surname. A patient with the same name and a different address was
identifi ed. The elderly patient was incorrectly registered as someone younger and with a different
medical history.
At no point was there verifi cation of the patient with their details, and discussions with the patient
and their family did not identify the error in date of birth or discrepancy of past history.
The patient presented as articulate, didn’t look unwell, observations were normal and reported that
they had overdone it recently. A category four triage classifi cation was allocated to the patient.
The patient was reviewed by the ED intern who recorded a heart rate of 100bpm, longstanding
shortness of breath, and back and shoulder pain. A diagnosis of a torn muscle was made and the
patient was discharged following discussion with the ED senior doctor.
Prior to the patients discharge a junior nurse recorded observations and noted a heart rate
of 120bpm. There was no evidence that this was discussed with any nursing or medical staff.
The patient re-presented to ED a number of hours later where it was identifi ed that the patient
was incorrectly registered on the fi rst presentation to ED. The patient was diagnosed with bilateral
pneumonia which deteriorated rapidly and required intubation.
How did the health service address the issues identifi ed?
• changed the triage/registration process so that patients are seen fi rst by the triage nurse and
then registered by the administration staff
• reinforced the verifi cation of patient details to ensure name and date of birth are matched
• introduced an ED electronic tracking system to replace a paper-based system
• reviewed the patient monitoring and documentation process
• reviewed staff skill mix and rostering, and
• reviewed the patient identifi cation policy and procedures for compliance with the commission’s
patient identifi cation initiatives. This can be assessed at: http://www.safetyandquality.gov.au/
internet/safety/publishing.nsf/Content/PriorityProgram-04_Initiatives
Consumer participation
18
Sentinel event program annual report 2009–10
Accurate identifi cation of patients can be a challenge in complex health care systems because
a variety of circumstances may lead to incorrect patient identifi cation. Patient characteristics such
as small children who are unable to identify themselves or patients with communication diffi culties
caused by dementia, impaired cognition or language barriers can increase the risk of incorrect
patient identifi cation. Additionally patients with the same or similar names can create complexity
and confusion as the previous case study illustrated.
Good health care is best achieved through an active and positive partnership between the patient
and the health care professional. Consumers need to be encouraged to be involved as much as
possible in every decision about their health. Consumers should ask questions when unsure about
the care being provided.
A booklet 10 tips for safer health care explains how and why things can go wrong, and how
consumers can work in partnership with health care professionals. This is available at
http://www.health.gov.au/internet/safety/publishing.nsf/Content/10-tips.
Monitoring patient experience
The patients’ perception of their hospital stay is a key indicator of health care quality.
The department supports a range of initiatives that promote and support consumer involvement
in decision-making about their treatment and care, in service development and quality improvement,
and more broadly, in health policy developments.
A key mechanism for monitoring patient experience for health services is the Victorian patient
satisfaction monitor survey. Patient satisfaction may be thought of as the degree to which a patient
feels they have received quality health care. Measurement of satisfaction is an essential part of
quality assessment.9
Currently 108 health services participate in this survey. More information, including an annual
report is available at: www.health.vic.gov.au/patsat/index.htm. Health services are provided with
this collated information, benchmarked against like organisations, to enable areas of strength and
opportunities for improvement to be identifi ed.
Australian Charter of Healthcare Rights in Victoria
The new Australian Charter of Healthcare Rights in Victoria was launched in September 2009,
superseding the previous Victorian Public Hospital Patient Charter.
The aim of the Charter is to ensure high quality health care provision, which embodies the seven
health care rights. The Australian Charter of Healthcare Rights in Victoria brochure can be ordered
in English, Braille and 25 other community languages and may be accessed as an audio fi le at:
http://www.health.vic.gov.au/patientcharter/.
9 A. Chow, E. K. Mayer, A.W. Darzi, T. Athanasiou 2009, ‘Patient-reported outcome measures: the importance of patient
satisfaction in surgery’. Surgery vol.146; Iss.3, pp 435-443.
19
Doing it with us not for us: Strategic direction 2010–13
In September 2009, the Minister for Health and the Minister for Mental Health approved a new
comprehensive set of standards and indicators for health services to report against to continue
monitoring the Doing it with us not for us policy implementation. These standards and the intended
outcome of the new strategic direction is for health services to work with consumers, carers and
community members to improve health policy and planning, care and treatment, and the wellbeing
of all Victorians. Health services have fi ve new standards and associated indicators to achieve and
report on, and these are set out in the policy at: http://www.health.vic.gov.au/consumer/participate.htm
Cultural responsiveness framework
The Cultural responsiveness framework: guidelines for Victorian health services, was launched
in September 2009. It consolidates the former Health Service Cultural Diversity Plan achievements,
and aims to improve and extend health services’ capacity and performance in providing culturally
and linguistically responsive health care. A copy of the framework can be accessed at:
http://www.health.vic.gov.au/cald
20
Sentinel event program annual report 2009–10
21
Clinical effectiveness mean ensuring the right care is provided to the right patient who is informed
and involved in their care at the right time by the right clinician with the right skills in the right way.
The department requires strategies to be in place to ensure:
• clinicians are empowered to improve clinical care delivery
• clinicians actively involve consumers as partners in their care
• clinical care is evidence-based
• standards of clinical care are clearly articulated and communicated, and
• quality improvement activities are reviewed externally.
Clinical effectiveness is achieved through empowering clinicians to introduce, monitor and evaluate
evidence-based practice which involves the use of performance measures, clinical indicators and
clinical audits.
To further enhance this work an evidence-based adult general observation chart is also being
developed by the commission. The fi rst phase has been completed and consisted of a research
project which compared existing charts to fi nd the best chart for recording observations. The results
of this research may be accessed at:http://www.safetyandquality.gov.au/internet/safety/publishing.
nsf/Content/RaRtCD_EBA-GOC
Retained instrument requiring further surgical procedure
Peri-operative practitioners play a vital role in enhancing the surgical patient’s safety through
ensuring the correct surgical count. However, the retention of instruments or other material may
occur in a variety of circumstances beyond operating theatres. These include procedural areas
where invasive or diagnostic procedures take place such as wards, endoscopy, radiology and
intensive care units.
The World Health Organization (WHO) Surgical Safety Checklist was launched in 2009 and includes
a core set of safety checks for use in any operating theatre environment. It is designed to improve
safety by focussing on anaesthetic safety practice, ensuring correct site surgery, avoiding surgical
site infection and improving communication within the operating team. To fi nd out more about the
WHO surgical safety checklist visit: http://www.who.int/patientsafety/safesurgery/ss_checklist/en/
index.html
There were nine events classifi ed as ‘retained instruments or other material’ reported to the sentinel
event program in 2009–10. These incidents are distinct in that patients required re-operation or
further surgical procedure to remove the foreign body. Although this classifi cation accounted for the
greatest number of events reported in 2009–10, the degree of impact from retained instruments or
other material varied from no harm to temporary reduction in function as outlined in Figure 5.
Clinical effectiveness
22
Sentinel event program annual report 2009–10
Case study
A patient underwent a diagnostic laparoscopy for severe abdominal pain. No cause of pain
was found and the patient was discharged home the following day. The patient re-presented to
hospital on numerous occasions with various complaints over the following months. A diagnostic
laparoscopy was performed and a disposable item was found in the pelvis.
A review of this incident identifi ed that the supplied disposable item had been reported to the
supplier as faulty prior to the event, and had been replaced by the supplier.
Although there was a process for addressing defective disposable equipment, the item was
still in use several weeks after the fault was reported to the supplier. Repeat supplies of this
disposable item proved faulty again and subsequently this item was withdrawn and the product
and supplier changed.
How did the health service address issues identifi ed:
• developed a defective equipment policy and procedure
• reinforced to staff that medical device adverse events should be reported to the Therapeutic
Goods Administration (TGA)
• implemented an improved warning system for when suspected problems occur but the
disposable equipment is still in use
• reviewed the peri-operative count sheet to include certain disposable operative equipment
in the mandated operative count, and
• reminded staff of the need for vigilance when removing disposable instrumentation from patients
during surgery.
Enhancing effective communication
Quality and safe patient care relies on effective communication because of the countless daily
interactions that occur between health care providers. Lack of effective communication may occur
between staff, across disciplines, units or hospitals, and between staff and patients or their family,
carer or advocate.
When effective communication is absent, patient care is compromised as evidenced
by communication being among the most consistently reported contributing factors
to sentinel events in Victoria for the past eight years.
Improving communication requires a systems approach to include a culture that emphasises open
communication. A range of initiatives are underway, both in Victoria and nationally to facilitate timely
and clear exchange of communication between health professionals especially around the clinical
handover process.
When surveyed about the clinical handover process by the Victorian Quality Council (VQC), Victorian
health services identifi ed ‘shift-to-shift handover’ and inter-hospital transfer as two signifi cant areas
of concern. The VQC subsequently developed standardised handover tools and a range of clinical
handover resources that may be accessed at: http://www.health.vic.gov.au/qualitycouncil/activities/
handover.htm
23
A national guide for improving clinical handover practices at shift change was endorsed
by Health Ministers in April 2010. Further information on this national guide can be accessed
at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-
05#NCHIPP
The Victorian Managed Insurance Authority (VMIA) is piloting a similar communication tool with
a major Victorian tertiary health service. The Identity, Situational, Background Assessment Request
(ISBAR) is a simple, practical tool to guide staff on how they structure and exchange information.
This can be accessed at: http://www.vmia.vic.gov.au/display.asp?entityid=6556
Clinical handover has also been recommended to surgeons as an essential component of care
by the Victorian Surgical Consultative Council (VSCC). Guidelines for clinical handover were issued
by the VSCC in July 2010 and can be accessed at: http://www.health.vic.gov.au/vscc/vscc-
guidelines-_and_-practice-statements#c02
This guideline will be further enhanced by the statewide rollout of standardised documentation
for post operative orders undertaken by VSCC in partnership with VMIA. Resources and tools
can be accessed at: http://www.vmia.vic.gov.au/display.asp?entityid=6556
The Victorian TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety)
overseen by the VQC is another project that is underway to enhance effective communication.
This program is an evidence-based teamwork training system designed to improve collaboration,
communication and patient safety within health care. Information can be accessed at: http://www.
health.vic.gov.au/qualitycouncil/activities/teamstepps.htm
24
Sentinel event program annual report 2009–10
25
All staff employed within health services must have, and be supported to have, the appropriate skills
and knowledge required to fulfi l their roles and responsibilities within the organisation. Processes
should be in place to support appropriate:
• selection and recruitment of staff
• credentialling of clinical staff including annual review of practice
• maintenance of professional standards, and
• control of the safe introduction of new therapies or procedures.
Case study
The patient’s post operative recovery was stable after undergoing elective abdominal surgery.
On day two the patient experienced abdominal distension and vomiting. On day fi ve, oxygen
therapy was commenced for suspected bilateral lung collapse and fl uid boluses were given, after
which the patient appeared to improve.
On day seven the attending surgeon went on leave without handing over to the on-call surgeon.
The anaesthetist reviewed the patient and was concerned about the deteriorating patient’s
condition and a scan was performed. The junior medical offi cer conveyed the scan results
to the on-call surgeon who ordered a treatment plan. Over the next 24 hours the patient’s
condition improved temporarily.
Subsequently, the patient deteriorated over the next few days and was reviewed by the junior
medical offi cer and the anaesthetist with telephone discussion with the on-call surgeon, and
a treatment plan was put in place. Further review by the junior medical offi cer noted the patient
was stable.
The next day the patient deteriorated suddenly and following resuscitation required transfer
to a tertiary hospital.
How did the health service address issues identifi ed:
• convened a multidisciplinary group to review the surgical care, clinical pathway, processes
and resources provided to major or high risk cases and identify areas for improvement
• implemented a senior medical staff leave coverage process to include a notifi cation and patient
handover process
• educated senior medical staff on responsibilities and expectations in relation to supervising
and supporting junior medical offi cers on rotation within the hospital
• updated the intern orientation manual to include general guidelines for junior medical offi cers
working on the general wards
• reviewed the clinical instability and MET policy and staff training program, and
• developed a clinical escalation policy along with a staff training program.
Effective workforce
26
Sentinel event program annual report 2009–10
Recognising and responding to clinical deterioration
Patients who experience clinical deterioration may exhibit warning signs such as abnormal vital signs
that are often not identifi ed or poorly addressed leading to unexpected outcomes. Early recognition
and response to clinical deterioration may prevent these events.
The commission commenced its Recognising and Responding to Clinical Deterioration program
in 2009. This program aims to improve the recognition of and response to patients who deteriorate
in hospitals and other acute care facilities.
A nationally agreed consensus statement regarding the essential elements for recognising and
responding to clinical deterioration has been completed and endorsed by Health Ministers in April
2010. This generic document was developed to apply to all patients in all acute care facilities in
Australia. An implementation and action guide will be developed to support use of the consensus
statement and is expected to be completed in early 2011. Further information may be accessed at:
http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/prog-patientsrisk-lp
Recognising and responding to clinical deterioration is a key strategic priority in Victoria and nationally.
It is one of the fi ve new draft standards being developed by the commission,10 and has been endorsed
by the Australian Health Ministers’ Advisory Council and the Australian Health Ministers’ Conference.
Clinical Engagement Program
The department has released Partnering for performance: a performance development and support
process (2010), which aims to support the process of regular performance appraisal, and review and
strengthen the relationship between senior doctors and their health services.
Partnering for performance provides a suite of processes and tools to support clinical practice
and implementation of the Credentialling and defi ning the scope of clinical practice for medical
practitioners in Victorian health services policy (2009). Included is a guide which provides tips
and checklists to assist participants with reviewing performance, performance development
conversations and goal setting.
It also includes the Understanding clinical practice toolkit which incorporates tools to aid individual
doctors, their peers and organisations to understand and monitor clinical practice. The tools
included are:
• peer review
• adverse occurrence screening and targeted case note review
• mortality and morbidity reviews
• clinical audit
• clinical indicators, and
• patient satisfaction and complaints.
The department has recently engaged a consortium led by The Royal Australasian College
of Medical Administrators (RACMA) to develop and deliver a training program to support the
implementation of Partnering for Performance focusing on undertaking performance conversations.
More information is available at: http://www.health.vic.gov.au/clinicalengagement
10 Australian Commission on Safety and Quality in Health Care, National Safety and Quality Heath Service Standards, August
2010. Accessed at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/home
27
Health services should have a risk management system in place which integrates the management
of fi nancial, occupational health and safety, plant, equipment and clinical risk.
Minimising clinical risk and improving safety of care requires a systems approach where it is diffi cult
to make errors. It also requires a just culture where systems and processes are the focus of
investigation rather than blaming individuals.
Potential risks may be reactively identifi ed or fl agged through incident reporting, screening medical
records, or analysis of administrative data for clinical incident markers.
Clinical risk management and improvement strategies should be integrated within improvement
and performance monitoring functions.
Air embolus – a rare occurrence
Air embolus or the accidental introduction of air into the blood circulation is associated with high
morbidity or mortality.11 While air embolus may occur with trauma, it most commonly occurs during
medical intervention such as intravascular catheterisation or surgery. Despite the potential risk
of air embolism associated with medical intervention, only one case of air embolism has been
reported in Victoria since the commencement of the sentinel event program in 2002. Although
sentinel events are reported voluntarily, this rare occurrence is encouraging given that Victorian
public hospitals are continuously treating a growing number of patients and performing more surgical
procedures.2 Whilst the occurrence is rare, this single case warrants review given the potential
to impact negatively on quality of life, independence, and function.
Case study
A patient was admitted for elective coronary artery bypass graft surgery. Prior to transferring
the patient into the operating room, the surgeon wanted to trial a new room confi guration to allow
easier access.
The patient was connected to the bypass machine and a pre-cardiopulmonary bypass checklist
was completed. The patient’s heart was cannulated, the bypass machine was turned on, and the
vent pump was turned on. It was observed that the air in the vent line was moving in the wrong
direction, toward the patient. The cannula in the heart was removed immediately, the patient was
placed into a trendelenburg position and the aorta was opened to allow air bubbles to escape.
It was identifi ed that a line had been placed incorrectly into the vent pump on the bypass machine,
which was rectifi ed prior to surgery recommencing.
Post-operatively the patient was slow to wake with some initial seizure activity. An MRI showed
changes that were reported as consistent with air emboli. The patient was discharged following
an intensive care unit admission, and prolonged ward and rehabilitation admission.
11 S. Sviri, W. P. D. Woods, P. V. Van Heerden 2004, ‘Air embolism: a case series and review.’ Critical Care and Resuscitation
vol. 6 pp271-276.
Risk management
28
Sentinel event program annual report 2009–10
How did the health service address issues identifi ed?
• improved the bypass machine setup to ensure easy visualisation and access
to critical components
• applied permanent highly visible directional arrow markings to the vent pump
on the bypass machine
• introduced new vent lines which contain a one-way valve, and
• introduced a policy where clamping the vent line and priming the cardioplegia prior
to connection to the patient is incorporated into all cardiothoracic surgery practice.
Medication errors – interruption during administration
Medication error may occur during any stage of the medication process of prescribing, dispensing,
storage, preparation, administration and monitoring.
Case study
During the evening medication round in an aged care hostel, the staff member opened a resident’s
dose administration aid and realised that the medication was prescribed for a non-routine
administration time, and was not due for administration until two hours later. The medication was
subsequently put aside on the drug trolley.
The staff member continued with the medication round and administered medications to four other
residents when the medication round was interrupted.
Following the interruptions the staff member resumed the medication round and inadvertently
dispensed the medication they had put aside on the drug trolley to another patient.
The event was immediately reported and the resident was transferred to the affi liated hospital.
How did the health service address issues identifi ed?
• introduced minimal interruption procedures and a highly visible vest for staff undertaking
medication rounds to alert others not to disturb except in an emergency
• kept medications prescribed for non-routine administration times to an absolute minimum
and fl agged these medications on the medication chart
• revised the Medication Management Procedure to include procedures for medications
removed from the pack and not given immediately, and procedures for occasions when
the resident is absent, and
• developed a staff education program on medication.
Beyond compliance strategy
Beyond compliance aligns and translates concepts of safety and quality in acute health to public
sector residential aged care services (PSRACs), where appropriate, through integration within
existing organisational governance and operational frameworks. It emphasises linking the domains
of the Victorian clinical governance policy framework to promote an integrated, sustainable approach
to safety and quality.
29
There are 194 PSRACS in Victoria with at least 6,400 residential aged care beds.
Through Beyond compliance investment in research and partnerships development, a range
of initiatives has been developed. Further information can be accessed at: http://www.health.vic.gov.
au/agedcare/publications/beyond_compliance.htm
Mental health
Case study
A patient with a diagnosis of borderline personality disorder was placed in seclusion with
constant visual observation because of agitation and ongoing suicide attempts using clothing for
strangulation. All bedding was removed and the consumer was left with a mattress and a pillow.
An agency nurse was asked to conduct constant visual observations through the seclusion room
window; however the patient was not in view as they had their back to the window. Shortly after
commencement of seclusion, the agency nurse noticed the consumer tearing at the pillow. They
had tied a strip of the material around their neck. There was a delay in reaching the patient
as the agency nurse was not given a key to the seclusion room and had to seek assistance from
another nurse.
A medical emergency (Code Blue) was called; the patient was resuscitated and was transferred
to the emergency department. The patient survived with no physical adverse outcome.
How did the health service address issues identifi ed?
• improving access to seclusion rooms – key securely centrally located
• placed a non-breakable observation mirror in the corner to view obscured angles in the room
• improved orientation of agency staff to the unit to ensure awareness of emergency alarms and
processes, and
• purchased non-shreddable mattress and pillows.
Victorian mental health quality framework
The department has developed the Victorian mental health quality framework. This framework
identifi es the key dimensions of quality, collates existing quality and safety frameworks, and
provides a reference source for national standards, legislative requirements and existing guidelines
and policies.
National Standards in Mental Health Services and Clinical Review Program
A project to implement a revised National Standards for Mental Health Services is underway.
This project aims to develop a national clinical audit tool, and to undertake promotional activities
associated with the implementation of the revised national standards to ensure a consistent
approach across all jurisdictions and sectors in Australia.
The Offi ce of the Chief Psychiatrist is embarking upon a new round of clinical service reviews, under
the auspices of the Quality Assurance Committee. It will target select service settings and functions
and practices such as, triage, community case management and seclusion and restraint practices.
30
Sentinel event program annual report 2009–10
Working with the Suicidal Person: Clinical Guidelines for
Emergency Departments and Mental Health Services
This evidence-based clinical guideline aims to assist clinicians in emergency departments and mental
health services with the management and assessment of people who have either attempted suicide
or are at risk of suicide. The guidelines will be published with a range of accompanying reference
resources and is scheduled to be completed in 2010.
Restraint and seclusion practices
Restraint and seclusion practices in public mental health services, while regulated by legislation,
are highly restrictive interventions that impact on the freedom and autonomy of patients. In 2005,
restraint and seclusion was identifi ed as one of four national safety priorities in mental health.
The Chief Psychiatrist in partnership with the Victorian Quality Council, the Mental Health Drugs and
Regions Division and the mental health sector has focussed effort on reducing the use of restraint
and seclusion in Victoria.
This effort targeted systemic practice changes, active participation in national projects, and
implementation of several local projects, clinical leadership forums, the development and roll-out
of statewide training and education programs, and a clinical audit program.
The project report Creating safety, addressing restraint and seclusion practices (2009) recommended
that health services reduce and where possible eliminate the use of restraint and seclusion. The
new Mental Health Bill will introduce another level of safeguards to ensure restraint and seclusion
practices are used as an intervention of last resort.
31
The following terms are used frequently in this report. The department acknowledges that their
usage varies and that a number of defi nitions are used in the literature.
adverse event an unintended injury or complication that results in disability, death or prolongation
of hospital stay and is caused by health care management rather than the patient’s
disease
ABO blood
group
a system for classifying human blood based on the antigenic components of blood
cells and their corresponding antibodies
behavioural
assessment
processes involved in establishing a patient’s cognitive state, particularly whether
the patient is at risk of wandering, absconding or causing harm to staff
clinical
guidelines
any policy, procedure or guidelines concerning the processes involved in the clinical
management of patients
clinical risk
management
an approach to improving quality in health care that places special emphasis
on identifying circumstances that put patients at risk of harm and then acting to
prevent or control those risks
clinical
governance
a health service board’s accountability for ensuring a framework and rigorous
systems are established so health care safety and quality are monitored, evaluated
and continuously improved
clinical pathway a treatment regime agreed by consensus that includes all the elements of care,
regardless of the effect on patient outcomes
cost direct and indirect activities involving a negative impact, including injury, death,
increased length of stay, time loss, money loss, service disruption, and reputation,
political and intangible losses
harm death, disease, injury, harm, suffering or disability experienced by a person
hazard a source of potential harm or a situation with a potential to cause loss
incident an event or circumstance resulting from health care that could have, or did, lead to
unintended or unnecessary harm to a person and/or a complaint, loss or damage
incident severity
rating (ISR)
a method to quantify the actual or potential consequences of an incident
or near miss
monitor to check, supervise, observe critically or record the progress of an activity
or system on a regular basis to identify change
morbidity incidence of disease
mortality death rate
near miss an incident that did not cause harm
risk the chance of something happening that will have an impact on objectives; it is
measured in terms of consequence and likelihood
risk assessment the overall process of risk analysis and risk evaluation
risk evaluation the process used to determine risk-management priorities by comparing the level
of risk against predetermined standards, target risk levels or other criteria
risk
management
the culture, processes and structures that are directed to the effective management
of potential opportunities and adverse effects
Glossary
32
Sentinel event program annual report 2009–10
root cause a signifi cant factor that contributed to an incident
root cause
analysis (RCA)
a systematic process where the factors that contributed to an incident are identifi ed
risk-reduction
action plan
strategies required to reduce the risk of similar adverse patient outcomes occurring
in the future
sentinel event a relatively infrequent, clear-cut event that occurs independently of a patient’s
condition; it commonly refl ects hospital system and process defi ciencies, and
results in unnecessary outcomes for the patient
underlying cause the systems or process-cause that allow for the proximate cause of an event
to occur
VAED Victorian Admitted Episodes Data Set
VHIMS Victorian Health Incident Management System
33
Appendices
Appendix 1: Incident severity rating (ISR)
The VHIMS ISR methodology was developed following analysis of methodologies used nationally
and internationally. This included methodologies suggested by the World Health Organization and
used by the National Health Service in the United Kingdom.
The ISR methodology provides a more consistent classifi cation of incident severity. It also allows
Victorian incident data to be mapped to a variety of other methodologies.
The ISR methodology can be consistently applied across all clinical (patient) and occupational health
and Safety (OHS) incidents. The ISR is based on:
• the actual and potential impact to those involved in the incident
• the actual and potential impact to the organisation.
The impact to the people involved is automatically derived from three related questions, these are:
1. degree of impact
2. level of care
3. treatment required.
VHIMS will derive an ISR depending on the values selected by the end user in each of the three lead
questions. Following are the specifi c details relating to each element of the ISR algorithm.
ISR scale
1 Severe/death
2 Moderate
3 Mild
4 No harm/near miss
34
Sentinel event program annual report 2009–10
Defi nition – degree of impact
Where ‘Harm’ includes disease, injury, suffering, disability and death:12
• disease – a physiological or psychological dysfunction
• injury – damage to tissues caused by an agent or circumstance
• suffering – experiencing anything subjectively unpleasant. This may include pain, malaise,
nausea, vomiting, loss (any negative consequence, including fi nancial) depression, agitation,
alarm, fear or grief
• disability – any type of impairment of body structure or function, activity limitation and/or restriction
of participation in society, associated with a past or present harm.
No harm – did not
reach the subject
There was no harm to the subject, that is, the incident did not reach the subject.
No harm – did
reach the subject
The incident reached the subject, but there was no harm caused.
No harm –
signifi cantly
inconvenienced
The subject was signifi cantly inconvenienced in relation to time, travel, wages,
lifestyle and family impact as a result of the issue and/or incident.
Harm – but no
loss or reduction in
functioning
The subject experienced harm but did not have a loss or reduction in functioning
as a result of the incident.
Harm – temporary
reduction in
functioning
One or more systems/components of the subject’s body are able to operate,
fulfi lling their purpose or role, but not to the level they could prior to the incident.
The subject is likely to recover from this reduction in the short-medium term.
Harm – temporary
loss in functioning
One or more systems/components of the subject’s body are no longer able
to operate normally, fulfi lling their purpose or role. The subject is likely to recover
from this loss within the short-medium term.
Harm – permanent
reduction in
functioning
One or more systems/components of the subject’s body are able to operate,
fulfi lling their purpose or role, but not to the level they could prior to the incident.
The subject is not likely to recover from this reduction.
Harm – permanent
loss in functioning
One or more systems/components of the subject’s body are no longer able to
operate normally, fulfi lling their purpose or role. The subject is not likely
to recover from this loss.
Harm – death The subject died unexpectedly at the time of, or following the incident.
Unknown The degree of harm caused to the subject, due to the incident, is not known
at this time.
12 Australian Commission for Safety and Quality in Healthcare (ACSQHC)
35
Defi nition – level of care
No signifi cant
change
The subject did not require any signifi cant extra care or increased length of stay
and/or higher care as a result of the incident.
Current setting
–increased
observation,
monitoring and/or
length of stay
The subject required increased observation, monitoring and/or length of stay
within their current setting, for example, ward. The subject was not transferred
elsewhere to a higher level of care.
Internal transfer
to a higher level
of care and/or
specialled
The subject was transferred internally within current organisation to a higher level
of care, for example, ICU and/or required specialling that is one-on-one care.
External transfer –
non inpatient
The subject was transferred externally to another health care provider for care,
but was not admitted.
External transfer –
inpatient admission
The subject was transferred externally to another health care provider,
for a higher level of care, for example ICU.
Not applicable The Level of Care is set to ‘Not applicable’ when the degree of impact was
‘Death’.
Unknown The change in level of care required by the subject, due to the incident, is not
known at this time
Defi nition – treatment required
No treatment Following a clinical review, intervention was deemed not required.
Minor treatment
including fi rst aid
The subject required a simple/minor intervention as a result of the incident.
For example: blood tests, xray, dressings, medications e.g. panadol, peripheral
IVT, urinary catheter insertion, nasogastric tube etc.
Advanced
treatment
The subject required signifi cant medical, diagnostic or surgical intervention as
a result of the incident. For example; MRI, CT, medications such as adrenaline,
insertion CVC or PICC line.
Not applicable The treatment required is set to ‘Not applicable’ when the degree of impact
was ‘Death’.
36
Sentinel event program annual report 2009–10
Appendix 2: Incident management process
37
Appendix 3: Source data
Table 1: Source data for reported events by classifi cation 2002–10
Classifi cation of event Frequency
2002
–03
2003
–04
2004
–05
2005
–06
2006
–07
2007
–08
2008
–09
2009
–10
Procedure involving the wrong
patient or body part resulting in
death or major permanent loss
of function
16 14 25 25 20 37 0
#
0
#
Suicide in an inpatient unit 5 1 4 7 11 7 7 6
Retained instruments or other
material after surgery requiring
re-operation or further surgical
procedure
9 8 5 6 8 11 3 9
Haemolytic blood transfusion
reaction resulting from ABO
incompatibility
0 1 1 0 1 2 1 2
Medication error leading to the
death of patient reasonably
believed to be due to the
incorrect administration of drugs
3 4 1 2 3 2 1 1
Maternal death or serious
morbidity associated with labour
or delivery
4 2 9 2 2 6 3 2
Infant discharged to wrong
family
0 0 0 0 0 0 0 0
Intravascular gas embolism
resulting in death or neurological
damage
0 0 0 0 0 0 0 1
Other catastrophic event
(includes near miss events)
42 55 77 49 37 37 53 36
Total 79 85 122 91 82 102 68 57
# From 2007-08, the national defi nition was revised to focus only on events that resulted in ‘death or major loss
of function’.
38
Sentinel event program annual report 2009–10
Table 2: Source data for events classifi ed as ‘other catastrophic events including
near miss’ events 2002–10
Other catastrophic events
sub-categories
2002
–03
2003
–04
2004
–05
2005
–06
2006
–07
2007
–08
2008
–09
2009
–10
Complication of emergency
management
9 11 6 4 2 1 4 0
Complication of anaesthetic
management
* 6 1 0 0 0 2 1
Complication of surgical
management
9 10 6 5 3 6 5 5
Foetal complication of delivery 3 0 1 2 2 0 2 2
Complication of inpatient fall
(death or serious morbidity)
2 10 11 4 5 7 5 2
Complication of fall (not resulting
in death or serious morbidity)
* * 18 1 0 0 0 0
Patient absconding from
inpatient unit with adverse
outcome
2 1 1 2 0 1 1 1
Infection control breach 6 7 8 3 2 2 2 2
Hospital process issue 9 7 0 6 0 3 0 2
Medication error (not resulting
in death)
* * 9 7 3 5 1 0
Misdiagnosis and subsequent
management
* * 4 3 3 1 2 4
Communication of test results * * 3 1 0 0 1 0
Other – mental health
management
* * 4 3 6 7 6 6
Other – unspecifi ed 2 3 5 8 8 4 1 5
A good catch/near miss 3 0 0 0
Procedure involving the wrong
patient or body part NOT
resulting in permanent loss
or death
* * * * * * 21 6
Total 42 55 77 49 37 37 53 36
*Sub-category not reported during the reporting period
39
Table 3: Comparisons of events by contributing factors expressed
as a percentage 2002–10
Contributing
factor Percentage of total contributing factors per reporting period
2002–3
#n=210
2003–4
#n=283
2004–5
#n=291
2005–6
#n=337
2006–7
#n=305
2007–8
#n=302
2008–9
#n=332
2009–10
#n=301
Procedures/
guidelines
32 41 31 43 32 43 36 34
Human
resources
17 17 24 14 15 18 15 23
Communication 16 17 27 20 18 16 20 17
Health
information
7 9 4 2 12 9 8 7
Equipment 7 7 4 5 4 7 8 10
Physical
environment
9 6 6 4 6 2 3 4
Facilities
management
6 3 1 3 2 2 3 1
Patient
behaviour
* * * 5 6 3 7 1
Course of
disease *
* * * 3 1 0 0 3
Other 6 0 3 1 4 0 0 0
Total 100 100 100 100 100 100 100 100
*Contributing factor not reported for reporting period #n= total number of contributing factors for reporting period
40
Sentinel event program annual report 2009–10
41
Clinical governance compliance checklist
Domain Domain descriptor
Equip 4.0
(Mandatory
criterion) Yes WIP No
Consumer
participation
Consumers are empowered to participate in their care. 1.1.2
Services respond to the diverse needs of consumers and the
community with humanity.
1.1.1
There is clear, open and respectful communication between
consumers at all levels of the health system.
1.1.2
Consumers provide feedback on clinical care and services
delivery and services learn from the feedback.
1.1.4
Clinical
effectiveness
Clinicians are empowered to improve clinical care delivery. 1.1.4
Clinicians actively involve consumers as partners in their care. 1.1.2
Clinical service delivery processes are streamlined and effi cient. 2.1.1
Clinicians participate in designing systems and processes. 2.1.1
Quality improvement activities are planned, prioritised and have
sustainability strategies in place.
2.1.1
Clinical care delivery is evidence-based. 1.12
Standards of clinical care are clearly articulated and
communicated.
3.1.5
Performance of clinical care processes and clinical outcomes
are measured.
1.1.4
Clinical performance measures, peer review and clinical audit
are used to evaluate and improve performance.
1.1.4
New procedures and therapies are introduced assuring quality
and safety issues have been considered.
2.1.2
Effective
workforce
Workforce development is planned and provides appropriate
skills and professional group mix.
3.1.3
The health workforce has the appropriate qualifi cations and
experience to provide safe, high quality care.
3.1.3
Risk
management
Clinical incidents are identifi ed, reported and investigated and
underlying systems issues are identifi ed.
2.1.3
Risks are proactively identifi ed, assessed and reported. 2.1.2
Organisational culture supports open communication and
a systems approach to learning from incidents.
2.1.3
Clinical processes and technology supports are designed to
minimise error and ensure clear, unambiguous communication.
3.2.1
A system for managing complaints or concerns about
a clinician is in place, promoted and is regularly reviewed.
2.1.3
Legislation and relevant Australian Standards are
complied with.
3.1.5
Policies and protocols are reviewed and managed. 3.1.5
This checklist provides a broad overview of the relationship between the Victorian clinical governance policy framework and the ACHS
EQuIP 4.0 mandatory criteria. Each domain is linked to the major mandatory criterion however other criterion may also apply.
42
Sentinel event program annual report 2009–10