clinical incident management in the nsw public health ... the nsw public health system looking,...

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Clinical Incident Management

in the NSW Public Health System Looking, Learning, Acting

January – June 2009

CLINICAL EXCELLENCE COMMISSION GPO Box 1614 Sydney NSW 2001 Tel. (02) 9382 7600 www.cec.health.nsw.gov.au Board Chair Professor Carol Pollock Chief Executive Officer Professor Clifford F Hughes, AO This publication is part of the CEC Incident Management Series. A complete list of CEC publications is available from the Director, Corporate Services (address above) or at www.cec.health.nsw.gov.au © Clinical Excellence Commission 2010 Any enquiries about this publication, or comments, should be directed to: Dr Tony Burrell Director, Patient Safety Clinical Excellence Commission GPO Box 1614 Sydney NSW 2001 Tel. (02) 9382 7600 Email. [email protected] Content within this publication was accurate at the time of publication. June 2010

NSW DEPARTMENT OF HEALTH 73 Miller Street North Sydney NSW 2060 Tel. (02) 9391 9000 Fax. (02) 9391 9101 TTY. (02) 9391 9900 www.health.nsw.gov.au This work is copyrighted. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgement of the source. It may not be reproduced for commercial usage or sale. Reproduction for purposes other than those indicated above, requires permission from the NSW Department of Health. © NSW Department of Health 2010 SHPN (CEC) 100032 ISBN 978-0-9805543-3-5 A copy of this report can be downloaded from the Clinical Excellence Commission website www.cec.health.nsw.gov.au or the NSW Health website www.health.nsw.gov.au Suggested citation Clinical Excellence Commission (CEC) and NSW Department of Health 2010. Clinical Incident Management in the NSW Public Health System 2009: January to June. Sydney

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TABLE OF CONTENTS Foreword ..........................................................................................................................

Executive Summary.......................................................................................................... 1

Background .................................................................................................................... 2

Key trends from IIMS ....................................................................................................... 4

Overall notifications ..................................................................................................... 4

SAC1 clinical incidents ................................................................................................. 8

Summary of principal incident types ............................................................................ 10

Complaint Management............................................................................................. 11

Maternal and Perinatal Care ....................................................................................... 13

Mental health incidents .............................................................................................. 13

Issues identified ............................................................................................................. 15

Clinical management of children and babies ............................................................... 15

Medication safety ....................................................................................................... 16

Transfer of care and clinical handover ........................................................................ 18

Update on projects and programs discussed in earlier incident management reports .... 19

Other Learnings ......................................................................................................... 21

Data Analysis Dashboard ........................................................................................... 25

APPENDIX 1: Managing Clinical Incidents in the NSW Health System ......................... 29

APPENDIX 2: Principal Incident Type Definitions and Data ......................................... 30

APPENDIX 3: Definitions ........................................................................................... 33

Reference List ............................................................................................................ 34

Executive Summary This report provides information on clinical incidents reported in the NSW public health system between 1 January and 30 June 2009. This work is part of the Clinical Excellence Commission’s (CEC) and Department of Health contribution to the NSW Patient Safety and Clinical Quality Program (PSCQP) established in 2004.

A clinical incident is any unplanned event which results in, or has the potential to result in harm to a patient.

Many of the approaches being used to improve patient safety in health care come from lessons learned in other high-risk industries like aviation, nuclear power and mining. In each we recognise that staff are human and are prone to mistakes. We all need to concentrate on identifying risks and putting systems in place that make it easy to do the right thing every time.

The PSCQP uses a “whole-of-system” risk management approach. Notifications through the Incident Information Management System (IIMS) are a key to knowing about risks in the health system. A vital ingredient is nurturing an open “reporting culture”. Analysis of reported incidents builds a “learning culture” around these events. Increasing the number of notifications is but one step. Continued learning and targeted action needs to follow.

Clinical incident notifications totalled 62,369 in this report period, a rise of 1.9 per cent compared with the previous six months and 6.5 per cent on the same period last year. The top five incident types continue to be falls, medication and intravenous fluid events, clinical management, aggression and behaviour/human performance. In this period, 757,347 patients were admitted to hospital for a total of 3,093,520 bed days. A further 944,087 people were treated in emergency departments (but not admitted). NSW Health performed 203,955 surgical procedures and assisted 34,611 births. The rate of serious (SAC1) incidents reported is 0.11 per 1,000 bed days, or 0.04 per cent of all admissions.

Themes continue to appear in IIMS data and root cause analysis (RCA) reports. These include the importance of clear and timely communication, the challenges of managing the increasing complexity, frailty and age of our patients and the importance of adhering to checking systems in all care processes. These findings are consistent in health systems around the world.1 2 3

The report also provides information about actions taken at both State and area health service level to address the issues identified. They include Statewide projects such as Between the Flags and work being done to facilitate the early diagnosis of Acute Coronary Syndrome. More importantly, local and immediate responses occur daily throughout the system, as clinical units identify problems and develop clinical solutions. The commitment of NSW Health staff to report and address risks is vital in maintaining the high quality of clinical care that patients have a right to expect.

1 Department of Health and Human Services USA (2008); Adverse events in hospitals: case study of incidence among Medicare beneficiaries in two selected Counties. (December 2008) OEI-06-08-00220 2 Pennsylvania Patient Safety Authority 2008 Annual Report, released April 2009. http://www.psa.state.pa.us/PatientSafetyAuthority/Documents/annual_report_2008.pdf 3 Council of the European Union (2009). Council Recommendation on Patient Safety, including the prevention and control of healthcare associated infection; 2947th Employment, Social Policy, Health and Consumer Affairs Council Meeting, Luxembourg, June 2009.

http://www.psa.state.pa.us/PatientSafetyAuthority/Documents/annual_report_2008.pdf�

Looking, Learning, Acting

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Background Patient safety and clinical quality have always been central to health care. While there have been increasingly rapid advances in our capacity to treat ageing patients and those with complex conditions, we need to ensure that quality care is delivered safely every time.

To improve patient safety, we must identify and notify incidents and risks. Reporting alone, however, will do nothing to reduce the risk of harm to our patients. A robust framework is required, built on the information from incident notifications and subsequent investigations of what has really occurred. Then we can aggregate and use the data to make improvements. These are the elements of the NSW Health Incident Management Policy and Framework.

People working in the NSW public health system are trained and encouraged to report all incidents through the Incident Information Management System (IIMS). This is accessible by all staff and is prominent on all computers in all public health facilities throughout the State. It helps clinicians and managers to address identified risks and to record their actions for future learning. It is both a notification tool and a database. All information is maintained and accessible for trend analysis and review. As would be expected, incidents where a patient has been harmed, or a serious risk identified are prioritised and explored in greater detail.

Serious clinical incidents and the results of their investigation must be reported to the NSW Department of Health, so that others can learn and be alerted to potential risks. One of the roles of the Clinical Excellence Commission (CEC) is to enhance learning from incident reporting. It conducts aggregated analysis and openly communicates the findings to health professionals, the Department of Health, the Minister and the public. This informs the “learning culture” needed to improve the quality and safety of patient care.

Another essential part of incident management is open communication with the patient, their family and carers, known as Open Disclosure.

Open disclosure is a frank discussion with a patient and their family/support person about a patient-related incident that may have resulted in harm or injury. The key principles of open disclosure include openness and timeliness of communication, acknowledgement of the incident, an apology, recognition of the reasonable expectations of the patient and their support person, confidentiality and support for staff.

These approaches are integral to the NSW Patient Safety and Clinical Quality Program. In addition to the CEC and Department of Health roles, clinical governance units have been established in each area health service, Children’s Hospital at Westmead, NSW Ambulance Service and Justice Health to assist with implementing the program. More information can be obtained at: http://www.health.nsw.gov.au/policies/pd/2005/PD2005_608.html

The information in each section of this report is presented “thematically” -

Looking (at the incident information) and

Learning (from analysis, what issues need to be addressed). Both drive the health service into

Acting (to improve the quality and safety of patient care in NSW)

http://www.health.nsw.gov.au/policies/pd/2005/PD2005_608.html�


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An incident is any unplanned event resulting in, or having the potential to result in harm to a patient. The term “incident” is very broad and provides comprehensive information on many areas where improvements could be made.

The NSW health system uses a severity assessment code (SAC) matrix. This allows the person notifying an incident to assign a ranking, known as a SAC score, by plotting the consequences (from serious to no harm caused) and the likelihood that it could happen again (from frequent to rare). There are four ratings. SAC1 indicates extreme risk and SAC4 low risk. The processes for clinical incident management, based on SAC rating, can be found in Appendix 1.


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Key trends from IIMS First we will look at aggregated incident notification data across the whole NSW health system. Analysis at this level allows a better understanding of trends and vulnerabilities. This is important, because incidents which occur uncommonly in one health service may have similar causes to incidents elsewhere. The collective findings provide early warnings, as well as meaningful information about what needs to be done to improve patient safety and clinical quality across the system.

Overall notifications The 62,369 clinical incident notifications in this report compare with 61,217 during the previous six months - a 1.9 per cent increase and 6.5 per cent on the same period last year. The rate of incident reporting (all SAC ratings) per 1,000 bed days has risen from 14.6 in 2005-2006 to 19.6 in 2008-2009 (see Figure 1). The rate of serious incidents reported is 0.11 per 1,000 bed days (July-December 2009), 0.04 per cent of all admissions. During the 2007-2008 period, the rates were 0.09 per 1,000 bed days and 0.04 per cent of admissions.

Figure 1: Clinical Notifications per 1,000 bed days

The rate of reporting continues to rise. This positively reflects increasing awareness of the value of reporting - whether or not harm occurred. The ongoing trend of increased reporting rates since IIMS was implemented is shown in Figure 1 and Figure 2. The rate of NSW incident notifications per admission remains consistent with international data4

The majority (91.84 per cent) of notifications were associated with medium or low risk (SAC3 or SAC4 – see Table 1). It is worth noting that in the current report period 5.76 per cent of incidents had not been allocated an actual SAC rating up to seven months after they were

and also tells us that we are still working toward a mature safety culture where every possible opportunity for learning is reported.

4 Department of Health and Human Services USA (2008); Adverse events in hospitals: case study of incidence among Medicare beneficiaries in two selected Counties. (December 2008) OEI-06-08-00220 4 Pennsylvania Patient Safety Authority 2008 Annual Report, released April 2009. http://www.psa.state.pa.us/PatientSafetyAuthority/Documents/annual_report_2008.pdf



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reported by staff. This suggests that a few managers are either not reviewing or not recording their review of a number of incidents. During the previous period, the rate was 4.10 per cent.

Figure 2: Clinical notifications by month 01/01/2006 to 30/06/2009

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The SAC1 data includes deaths of mental health patients being managed in the community (34 suspected suicides and a further nine where the cause of death is undetermined). These are included in the calculations below, even though the patients may not have been occupying a hospital bed at the time of their death.

Table 1: Prevalence of clinical incidents in the NSW public health system

SAC rating Number Percentage (%) of notifications

As a percentage (%)of all hospital admissions

Per 1,000 bed days

SAC1 327 0.52 0.04 0.11

SAC2 1,173 1.88 0.15 0.38

SAC3 26,525 42.54 3.50 8.57

SAC4 30,749 49.30 4.06 9.94

No SAC allocated 3,595 5.76 0.47 1.16

Total 62,369 100.00 8.24 20.16

Who reports incidents?

IIMS intentionally allows anonymous notification of incidents. Fourteen per cent of notifications in this reporting period, including seven per cent of the SAC1 incidents did not include the full name of the reporter. Many of these did, however, include the notifier’s designation. There was little difference overall in how anonymous notifications were managed, although a slightly higher percentage did not have documented actions at the time the report data was extracted.

Most incidents continue to be reported by nurses, as indicated in Figure 3. There may be a number of reasons, including the proportionally large number of nurses in the health care work force. Although doctors make up 13 per cent of the workforce, they continue to report only three per cent of incidents, but appear to report well on complex clinical issues.


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Figure 3: Clinical incidents by notifier

Notifier- Nursing81%

Notifier- Allied Health13%

Notifier- Corporate1%

Notifier- Other2%

Notifier- Medical3%

The most common incident types notified by nurses were patient falls, followed by medication/IV fluids; by doctors, clinical management; by allied health staff, including pharmacists, medication/IV fluids. Seventeen per cent of all SAC1 and 10 per cent of SAC2 incidents were reported by doctors. The overall percentage of SAC1 and SAC2 incidents is 2.41, but for doctors it represents 11.4 per cent of notifications.

The highest numbers of clinical incidents are again reported by staff in mental health inpatient units. This is reflective of a strong reporting culture around risks to the safety of all patients under their care, in areas where behaviour can be threatening or unpredictable. The top 10 reporting services are shown in Figure 4. Figure 4: Clinical incidents by specific services (top 10) for the period Jan-Jun 2009


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How incidents are classified – overview of principal incident types (PIT)

In addition to the SAC rating, staff making notifications in IIMS are prompted to make an initial assessment of the incident type. Clinical incidents are classified into 20 types, such as falls, medication/IV fluid. The rules for each classification are in Appendix 2. During subsequent analysis the principal incident type (PIT) is confirmed. This helps staff to describe the issues they are reporting and allows identification of common themes.

The top five PITs notified in the reporting period were falls, medication/IV fluids, clinical management (a broad area taking in all aspects of patient care, including diagnosis and treatment), aggression and behaviour/human performance. Each of these PITs is discussed in detail later in this report.

The types of incident reported largely reflect the patient groups and the clinical services provided. Falls remain the most common PIT in clinical units where older patients and those with balance and mobility problems are treated. It is interesting to note a significant increase in the incidents reported by obstetrics–maternity (31.5 per cent) and pathology (10.3 per cent) and a drop in reporting rates by surgical-general services (13.2 per cent) since the previous reporting period. Table 2: Top 10 specific services and their top five PITs respectively

Specific Service Top Five Principal Incident Types

Mental Health - Inpatient

Aggression - Aggressor

Behaviour/ human performance

Fall Medication/IV fluid

Clinical Management

Medicine - General


Pressure Ulcer Clinical Management

Accident/OHS

Aged Care - Geriatrics


Aggression - Aggressor

Pressure Ulcer Accident/OHS

Emergency Medicine

Clinical Management

Medication/IV fluid

Pressure Ulcer Aggression - Aggressor

Fall

Rehabilitation Fall Medication/IV fluid

Pressure Ulcer Accident/OHS Clinical Management

Obstetrics - Maternity

Clinical Management

Medication/IV fluid

Documentation Organisation Management

Services

Blood/Blood Product

Pathology Documentation Pathology Laboratory

Accident/OHS Blood/Blood Product

Clinical Management

Surgical - Orthopaedics


Clinical Management

Pressure Ulcer Documentation

Intensive Care Pressure Ulcer Medication/IV fluid

Clinical Management

Medical Device/ Equipment/ Property

Fall

Surgical - General

Fall Clinical Management

Medication/ IV fluid

Pressure Ulcer Documentation


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SAC1 clinical incidents These are incidents which resulted in significant risk or actual harm to the patient.

All SAC1 clinical incidents are subject to a root cause analysis (RCA), a thorough investigation technique that helps staff identify all the contributing factors. The goal is to identify all opportunities to improve systems for the safe delivery of quality care.

In this reporting period 327 SAC1 clinical incidents were notified, compared with 311 in the previous period and 281 in the same period last year. They include mandatory

reporting of deaths in custody and all events involving the wrong procedure or body part, regardless of the consequence for the patient.

Table 3: SAC1 incidents according to service and type

Service or PIT Jul-Dec 2008 Jan-Jun 2009

Mental health - suspected suicides and aggression 73 74

Maternal and Perinatal Stream (all PITs) 30 27

Blood/Blood Products 4 2

Clinical management – all clinical streams includes HAI, complaints about clinical care, patient identification and retained accountable items

172 181

Falls 16 26

Medication/IV fluids 2 4

Mandatory reporting - including deaths in custody 9 5

Incidents from all groups determined to be non-preventable following RCA*

5 8

Total 311 327

*these incidents were originally reported as SAC1 but found by RCA teams to be non-preventable. They have therefore been removed from their original classification (e.g. falls) but maintained as SAC1s.

Serious incidents involving patients who died

During the reporting period, 233 of the SAC1 incidents were associated with the death of a patient. This does not mean the incident was the cause of death. The clinical condition of patients is often highly complex. It may not be possible to determine precisely how much a particular incident contributed to the death.

It should be noted that all deaths in custody (mandatory reporting) and in circumstances where concerns were raised about management of a critically ill or dying patient, are classified as SAC1 incidents. Whenever any concern is raised about the care provided to a patient who subsequently dies, staff have been instructed to report a SAC1 incident, so that a detailed investigation (RCA) can be undertaken.

It is also NSW Health policy to review all deaths associated with care from NSW Health services5

5 Standard 3, Patient Safety and Clinical Quality Program PD2005_608.

. This process of retrospective review by experienced clinicians and coders adds another layer of scrutiny to ensure any underlying issues, which may not be apparent at the

http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_608.pdf

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time of death, are reviewed. A small number of SAC1 incidents are reported following routine death audits and these also undergo RCA.

Analysis of SAC1clinical incidents

There are a number of processes in place to review and aggregate findings of SAC1 clinical incidents from across the State. In addition to Department of Health processes, these include:

• The State RCA Review Committee which reviews all SAC1 clinical management, falls, medication/IV fluid and blood/blood product incidents to identify emerging themes and risks, inform further investigation and analysis, understand and articulate risks to patient safety and most importantly, facilitate feedback to clinical leaders and escalation of concerns to the Department of Health.

• The Mental Health Clinical Incident Review Committee (CIRC) which reviews and recommends actions in response to all RCAs related to patients managed by mental health, drug and alcohol services.

A similar sub-committee for maternity and perinatal RCAs will start in 2010. Review of these is currently facilitated by the Maternal and Child Health Unit.

The largest increase in SAC1 reporting related to patient falls. While there has been a gradual increase in the number of serious fall incidents reported, they remain less than 0.20 per cent of fall notifications. The previous incident report provided detailed information about factors which may increase the risk of patients falling. While much work is being done to standardise approaches to identifying and reducing falls risk, we are yet to see an impact on reporting rates. Further detail about falls reporting can be found in the IIMS Data Dashboard section of the report.


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Summary of principal incident types The number of incidents reported in IIMS under every PIT can be found on page 32. Below is a snapshot of the top five PITs reported in the January – June 2009 period.

Table 4: Top five PITs by SAC rating January – June 2009

Top Five Principal Incident Types Clinical Incidents SAC Rating Total

SAC1 SAC2 SAC3 SAC4 No SAC

Fall 26 195 6,381 6,175 540 13,317

Medication/IV fluid 4 59 2,943 6,931 987 10,924

Clinical management 181 478 4,041 3,920 627 9,247

Aggression - aggressor 3 48 3,599 2,016 140 5,808

Behaviour/ human performance 71 160 2,203 2,160 164 4,758

The rate of reporting for the top five PITs has been relatively consistent over the past three and a half years. The greatest increase in reporting has occurred under the Clinical Management PIT, although each has steadily increased (as shown by the trend lines in Figure 5).

Figure 5: Trends in reporting of top five clinical principal incident types

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Summaries of the top three PITs (Falls, Medication/IV fluids and clinical management) can be found in the IIMS Data Dashboard6

6 A data dashboard is a concise way of representing numbers and types of incident notifications. Using the same format in future incident reports will assist the reader in comparing these data sets over time.

section (pages 25-28)


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Complaint Management Ensuring the best clinical care is reliant not only on the skills and resources of the health system, but also on the partnerships built between patients, families and the care providers. NSW Health welcomes feedback about care provided, so that system improvements continue to occur. The IIMS database is used to record complaint details and actions taken in response to them.

There were 7,510 complaint notifications from January – June 2009. Over 98 per cent

of these were classified as SAC3 (24.49 per cent) or SAC4 (73.56 per cent). Most were received directly from the complainant, either by telephone (36.49 per cent), in person (22.24 per cent) or by letter (19.98 per cent). Complaints were also received via other sources including the Health Care Complaints Commission (6.31 per cent) and Members of Parliament (7.83 per cent). Occasionally a complaint may come from more than one source. The IIMS data shows that the three most common ways

• providing an explanation of the care or concerns (47.80 per cent)

that complaints were resolved were by:

• making an apology (35.89) • having a service provided (13.93 per cent).

In many instances, more than one action was undertaken to address the concerns raised. Over 80 per cent of complaints were resolved within 35 days.

What did people complain about?

Emergency departments (EDs) were the specific service identified in nearly 14 per cent of complaint notifications, followed by obstetric/maternity, ambulatory care services and general medical wards. Over 98 per cent of the complaints made about EDs were rated as SAC3 or SAC4.

As in previous reports, the top three complaint categories were:

• access to services (29.38 per cent) • communication with patients and between services (26.79 per cent) • treatment (26.22 per cent).

Nearly half of the complaints were about treatment being of a lesser standard or amount than was expected. A further 12 per cent were concerned about the co-ordination of treatment. Fourteen per cent related to the provision and management of medications.

RCAs related to complaints undergo the same health service and State-level review processes as clinical RCAs and are included in the SAC1 incident analysis sections of this report. Where an incident notification has already been received about the same episode of care, a single RCA is conducted to cover all issues identified in both the complaint and the incident notification. There were three SAC1 complaints notified during the report period. One related to a perinatal death, one a health care associated infection and another to clinical management.

NSW Health conducts annual statewide surveys of patients and carers to gather information about their experiences of care. The information is analysed to identify

opportunities for improvement. Approximately 80,000 patients and carers responded to the third survey in 2009. Ninety-one per cent of patients rated their care as good, very good or excellent, compared with 89 per cent in 2007.


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Being treated with dignity and respect, reducing anxiety and having staff available to provide emotional support, are central to how patients perceive their care. Medical literature reinforces the importance of actively involving patients in care, not only to improve their experience, but also to improve safety.7 8

A copy of the report for the 2009 survey can be found at:

http://www.health.nsw.gov.au/pubs/2009/pdf/patient_survey_2009.pdf

NSW Health has been working with staff to improve the quality and consistency of interactions with all patients and carers. This is one of many initiatives occurring across

NSW as part of the Caring Together – The Health Action Plan for NSW9. Most actions to address the specific issues raised in complaints occur at health service level.

Consumers can play an active role in their own health care.

Ten Tips for Safer Health Care

Be actively involved in your own health care.

Speak up if you have any questions or concerns.

Learn more about your condition or treatments by asking your doctor or nurse and by using other reliable sources of information.

Keep a list of all the medicines you are taking.

Make sure you understand what the medicines are for and how to use them.

Get the results of any test or procedure.

Talk to your doctor or other health care professional about your options if you need to go into hospital.

Make sure you understand what will happen if you need surgery or a procedure.

Make sure you, your doctor and your surgeon all agree on exactly what will be done.

Before you leave hospital, ask your health care professional to explain the treatment plan you will use at home.

Find out more at: www.health.nsw.gov.au/quality/10tips

7 McCauley K & Irwin RS (2006) Changing the work environment in ICUs to achieve patient-focused care. Chest 2006;130:1571-1578 8 Berntsen KJ (2006) Implementation of patient centeredness to enhance patient safety. Journal of Nursing Care Quality 21(1) 15-19 9 Caring Together – The Health Action Plan for NSW http://www.health.nsw.gov.au/pubs/2009/caring_together_hap.html

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Maternal and Perinatal Care Most pregnancies and births proceed with little intervention. Every pregnancy, however, requires a thorough risk assessment to ensure that mothers who need additional care at any stage are directed to appropriate services before the birth of the child. Safe maternity care relies on tiered networks to provide consultation and where appropriate, referral and transfer to higher levels of care. Facilities which provide maternity services in NSW are classified into six role levels, related to the complexity of planned care that can reasonably be managed and supported at the service. This care is dependent on neonatal and clinical support services and the skill mix of staff, rather than the particular skills of individual health professionals.

The pregnancy and birth cycle involves three stages - the antenatal period, the birth itself and the care of mother and baby afterwards. Care must consider the wishes of mothers and ensure the best health outcomes.

There were 34,611 births in NSW Health facilities between January and June 2009.

During this period, 2,047 incidents were notified by obstetric-maternity services. Twenty-seven of the notifications were classified as SAC1, compared with 30 in the previous

period. This included four incidents related to provision of breast milk. In one case the baby was given to the wrong mother to feed. Three babies received the wrong expressed breast milk. Seven of these were reported in the previous period.

Even with appropriate care, some babies die, sometimes without any indication of problems, sometimes due to known complications. Some perinatal (infant) deaths are reported to the coroner, others undergo RCA, however, in some cases the exact cause of death may never be determined. During the report period, there were three maternal deaths, each of which underwent RCA.

Review of the 27 maternal and perinatal SAC1 RCAs identified issues similar to those found in other clinical management incidents. They included poor communication,

inadequate care planning and delays in detecting and responding to patterns of clinical change.

Staff in all services need to have skills to respond to any emergencies which may arise, even if they occur rarely. Training staff to provide assistance when a “normal” birth does

not proceed is an essential component. NSW Health has made use of simulation training for doctors from across the State, using vacuum extraction equipment to assist with birth. A core group of doctors will receive extended training so they can pass on their expertise to colleagues in every health service.

Drafting and consultation about a Safety Notice on safe instrumental birth also occurred during the report period. The notice was released in July 2009.

Mental health incidents There were 10,069 mental health incident notifications during the current reporting period, compared with 10,312 in the previous period. Of these, 74 were classified as

SAC1. This includes serious behaviour/human performance (self harm/suspected suicide), aggression and clinical management incident types.

Mental health service clients, especially when acutely ill, are vulnerable to a number of potential risks, such as self-harm. This may be due to their own behaviour or to that of

other patients around them. Aggression incidents are the most common type of IIMS notification in mental health inpatient settings (41 per cent) and are a major concern for staff


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and patients. To improve the safety of patients in mental health services, NSW Health has developed a number of initiatives to help staff prevent and manage aggression and violence safely and therapeutically.

Training to manage aggressive and disorganised behaviour by patients is a core component of the occupational health and safety requirements for all area mental

health service staff. A formal review is being undertaken, to ensure that all necessary skills are included. An education and training working group has developed draft guidelines on training components for managing aggression in adult inpatient units. These will be included in the NSW Health policy on minimisation and management of disturbed behaviour in mental health facilities, which is currently being developed. It will also include a revised seclusion policy and a new restraint policy. NSW Health is undertaking a statewide seclusion reduction project in 2009-2010. Seclusion is currently used to manage aggression in mental health inpatient facilities. An essential component is exploring ways to improve management of agitation and other issues that contribute to the use of seclusion. The project will also identify alternative interventions to minimise the use of seclusion. The Department of Health has also funded a project to develop evidenced-based procedures and competencies for identifying and managing the risk of aggression in mental health intensive care units. Led by Justice Health during 2009-2010, it will focus on patients for whom standard indicators may not provide enough sophistication in clinical observation. Suspected Suicides

Reviews of suspected suicides of mental health patients in the community, and those on leave from inpatient units have identified opportunities for improvement including:

• the thoroughness of discharge planning • the need for comprehensive suicide risk assessments prior to approved leave from

inpatient units and during the period of community mental health care • situations where management of the patient is shared between health care

professionals. In response to these findings, NSW Health is leading a review of the statewide discharge planning policy for adult inpatient mental health services. The aim is to standardise and

improve communication, documentation and understanding of the issues which impact on safe discharge planning practices. A project to review and improve clinical skills in suicide risk assessment among mental health clinicians and others in key health care settings is continuing. It aims to enhance early identification and management of those at risk of serious self-harm. The department is also working with health services to improve “shared care“, where mental health patients receive care from more than one service in the community (e.g., GPs, psychologists, community mental health teams and private psychiatrists).


15

Issues identified Review of the aggregated data helps to identify key issues from incident notifications. Key issues identified during this reporting period are the clinical management of children and babies, clinical handover/transfer of care and safe management of medications for all age groups.

Clinical management of children and babies The CEC reviewed all clinical incidents reported between January and June 2009 about

children up to 16 years, to identify recurring issues needing to be addressed. They included six SAC1 incidents, although two related to care provided in 2008. Two others related to care of the same child at two different hospitals. The management of children presenting to emergency departments (ED) was explored.

The most common PIT identified for children in ED was clinical management (155). The subset of “treatment” (inadequate, delayed and in five cases, wrong) was the biggest category identified. Inadequate management of asthma and upper respiratory problems was identified in 20 of the incidents reported.

Paediatric medication was the next biggest group of issues (91). The most common medications involved were paracetamol (control of fever and minor pain) morphine (control of severe pain) and gentamicin (a very effective antibiotic requiring careful monitoring). Most of the medication incidents related to documentation and checking processes and caused no harm.

The most common time for incident reports about children in EDs was between 2.00 p.m. and midnight, with one-third occurring after 7.00 p.m. This reflects the peak times for paediatric presentations overall. The most common age group indicated in incident reports was children aged 10-14, followed by 2-4 year olds. Babies under two were the next highest group. In the SAC1 group, three were under two years and two were between eight and ten.

The clinical management incidents highlight the differences between adults and children when they are sick. Children’s conditions can change quickly and they can at

times appear to be better than they really are. This is well-known in paediatric care, but not necessarily for staff who most commonly see adult patients (e.g, those who work in adult care areas of large EDs, but may at times be asked to assist with children). Some incident reports and RCAs described how a child quickly became very unwell, when compared with his or her previous clinical signs, although a broader view may have identified a longer period of deterioration.

In hospitals without specialist paediatric services, the processes for preparing and transferring sick children can take some time to arrange. It is therefore essential to determine as early as possible what is wrong with the child and whether he or she needs to be transferred to more specialised care. The issues associated with this were the most common themes identified in the RCA reports. They included:

• delays in diagnosis and commencement of definitive treatment • inadequate or delayed communication of information to the most appropriate people • difficulties associated with escalating concerns and transferring the child to specialist

care.

These issues are very similar to those raised about adult patients.

In previous incident reports, information was provided about the CEC Between the Flags project (2008) and program (2009). This was initiated because of concerns identified


16

in relation to recognition and timely response to adult patients whose condition is deteriorating. See update on the adult Between the Flags program on page 19 of this report.

The Children’s Hospital at Westmead followed up on concerns that many children presenting with asthma left the hospital without a comprehensive plan for managing their symptoms. Health professionals wanted parents to have information on hand about how to manage their child’s asthma whether they were well, unwell or having an acute episode. The staff developed a form within the electronic medical record, which could be easily updated, provided to parents and remain as a permanent record of each child’s asthma management plan. As a result, over 80 per cent of children who are seen in the emergency department, leave with an asthma management plan. Studies have shown that implementation of asthma management plans can reduce GP visits and improve the overall well-being for these children.

Medication safety Medication and IV fluid incidents in NSW are regularly reviewed in order to identify common issues and to explore whether risks identified in international literature are also evident here. During the reporting period, a number of medication safety issues were explored. These included:

• a review of incidents related to use of midazolam • development of a policy framework for standardised management of anticoagulants • use of IIMS data related to infusion pumps as part of Statewide equipment tender.

Midazolam

Midazolam is used to sedate patients for minor procedures and to reduce anxiety. In December 2008, the National Patient Safety Agency (UK) issued a report on: reducing the risk of overdose with midazolam injection in adults10

. Nearly 500 incidents of an inappropriate dose of midazolam had been reported to the UK agency over a four-year period. Their review found that often an ampoule with a stronger concentration of midazolam had been wrongly selected when preparing the drug for intravenous administration. The Clinical Excellence Commission analysed incident data to see if there were similar issues in NSW. The review identified 88 incidents related to selecting the wrong dose-administration rate for intravenous infusions of midazolam. In 22 cases, the wrong strength of midazolam ampoule was selected for injection or infusion. The findings of the review were provided to NSW Health staff as a clinical focus report. This included recommendations for reducing both these risks, through training, storage and stock control (limiting supplies to the same lower-strength ampoules wherever possible).

The report was endorsed by the Reportable Incident Review Committee and distributed throughout the health system. The Department of Health reinforced the recommendations through a Safety Notice on the Safe use of Midazolam issued in December 2009.

10 NPSA (2008) Reducing risk of overdose with midazolam injections in adults. National Patient Safety Authority UK December 2008 NPSA/2008/RRR011 http://www.nrls.npsa.nhs.uk/resources/?entryid45=59896&q=0%c2%acmidazolam%c2%ac

http://www.nrls.npsa.nhs.uk/resources/?entryid45=59896&q=0%c2%acmidazolam%c2%ac�


17

Anticoagulants

Heparin, enoxaparin and warfarin are some of the most frequently-reported medicines involved in medication incidents. They are anticoagulants (blood thinners), used to reduce clotting. Anticoagulants are a crucial part of treatment for many conditions. There are, however, recognised risks associated with using them. The effect of the medicines can vary greatly between patients, particularly for those who have liver or kidney problems. Maintaining a therapeutic dose is critical. Underuse of these medicines may result in unwanted clotting, potentially leading to complications such as stroke. Overuse can result in excessive bleeding.

Evidence shows that guidelines to direct the use of anticoagulant medicines can reduce the risks associated with their use11 12

Intravenous medications and infusion pumps

. The Clinical Excellence Commission, in collaboration with the NSW Therapeutic Advisory Group and leading clinicians, has established the necessary elements of anticoagulant guidelines that should be available to all clinicians. NSW Health is drafting policy which will require all facilities to have compliant anticoagulant guidelines available. This is expected to reduce significantly the risks associated with these important medications.

Many of the incidents reported in IIMS involve medicines administered by injection or infusion13

• are often concentrated and have a more potent effect than those taken by other routes

. These have a higher potential to cause harm because they:

• often require significant preparation before they are given • are often given to the patient through programmable devices, such as infusion pumps,

which have their own potential for causing error. A number of different infusion pumps are used throughout the State. As each works slightly differently and multiple types may used in the same hospital, there is an inherent risk of errors during use. NSW Health has undertaken to reduce this error potential by contracting the purchase of one standard infusion pump for use across the State. This pump has the capability to install “smart” software designed to further reduce the potential for error.

Medication reconciliation

Every day patients are transferred between NSW hospitals, aged care facilities, community-based care and interstate services. Accurate information about their current medications needs to accompany them at each point, so that all necessary medications are continued at the right rate and dose. To ensure that this occurs, defined processes for recording medicines information have been developed. This is known as medication reconciliation. Data collected using the Medication Safety Self-Assessment for Australian Hospitals highlighted that many facilities in NSW are yet to implement formal medication reconciliation processes.

11 Schumock GT, Blackburn JC, Nutescu EA, Walton SM, Finley JM, Lewis RK (2004) Impact of prescribing guidelines for inpatient anticoagulation. Annals of Pharmacotherapy. 38(10):1570-5, 2004 Oct. 12 Bo S. Valpreda S. Scaglione L. Boscolo D. Piobbici M. Bo M. Ciccone G. (2007) Implementing hospital guidelines improves warfarin use in non-valvular atrial fibrillation: a before-after study. BMC Public Health. 7:203, 2007. 13 Slow, continuous injection over a long period of time


18

Ensuring continuity of care with medicines has been made a high priority. A group of doctors, nurses and pharmacists from across the State has assembled to discuss how best to implement these processes.

Medication Safety Self-assessment (MSSA)

The CEC co-ordinates the MSSA program in collaboration with the Institute for Safe Medication Practices in Canada and the USA. Other Australian States now contribute data. It provides facilities and pharmacists with a structured framework to assess current medication safety practices and allow them to:

assess the effectiveness of their medication policies and procedures in terms of patient safety outcomes

systematically identify gaps in the delivery of care that could constitute a medication risk and areas for improvement

measure performance against international benchmarks to identify continual improvement over time.

More information can be found at: http://www.cec.health.nsw.gov.au/programs/mssa.html

Transfer of care and clinical handover Issues associated with transfer of care

Patients often need to be treated by more than one clinical unit, service or speciality during their illness and recovery (e.g., ED to ward to GP/carer). This can require patients to move between different locations and to have their care overseen by different clinical teams along the way. They are also likely to be cared for by two or more different clinical teams (shifts) within a ward or unit in any 24-hour period. All these changes mean that it is essential for all relevant information about their history, planned care and current clinical condition to go with them at each point of transfer, along with the right equipment and belongings. This can present many challenges, including identifying who is leading decisions about treatment at each change. Most patient transfers occur without incident, because patients are in a stable condition or because specific risks have been considered and addressed prior to the transfer.

Issues associated with transfer of care identified in the IIMS data included:

• inadequate handover of information between treating teams • transfer of patients after-hours or when the clinical team cannot immediately review

them on the ward • transfer of patients whose condition is unstable • inadequate handover of information to the patient, family, GP or community supports

at discharge • delays in transporting patients between clinical units and hospitals

(ambulance/hospital transport services) • inability/delays in access to the most appropriate service (dependant on bed

availability).

http://www.cec.health.nsw.gov.au/programs/mssa.html�


19

Communication is a common thread in this group of incidents, whether the transfer occurred within the ward (shift-to-shift), within the hospital (ED to ward, theatre to

ward), or between hospitals.

When patients require transfer to a different hospital for specialised care, such as neurosurgery, or to higher-level care, such as ventilatory support, many more processes need to occur. These include locating a bed within the required clinical speciality and having the care of the patient accepted by an appropriately skilled clinical team/doctor. Communication is also needed about how best to prepare and maintain the patient in a stable condition during transfer. Having an escort with the required level of skill to be able to respond to any unexpected changes in the patient’s condition is also vital. The mode of transport, with the right clinical equipment must also be organised. These arrangements need to be made quickly, at all hours of the day or night, with as little disruption as possible to the patient’s immediate care needs.

Issues associated with clinical handover14

Within the ward setting, there are multiple communication and handover points. Hospitals have standardised processes, such as ISBAR

15

The need to improve clinical care handover has been well recognised. In recent years, many quality improvement projects have focussed on strengthening and standardising

these processes at health service level. To support improvement and standardisation of handover, NSW Health released a policy directive Clinical Handover – Standard Key Principles (PD 2009_060) in September 2009

, for transferring information about the patient to the next shift. There is an increasing trend for this to occur at the bedside, so that patients and their families are involved. Even with the best intentions, however, there can be gaps and interruptions to these processes in busy ward environments. Omitting a small piece of information, such as a minor change to the rate of intravenous fluid infusion, or discussions about end-of-life care can have major consequences later in the patient’s care.

16

Update on projects and programs discussed in earlier incident management reports

.

Between the Flags project

The data analysed for this reporting period again shows that failure to recognise and respond to deterioration in a patient’s condition can contribute to incidents. The CEC has continued to utilise the expertise of hospital staff to develop systems for early recognition and response to such changes. After broad consultation and trial, a standardised observation chart has been developed. Training in its use started early in 2010, following a launch by the Minister for Health. The chart assists staff to quickly recognise when a patient’s vital signs are outside the normal range and helps to trigger the appropriate level of response.

14 Clinical handover is the transfer of information, accountability and responsibility for a patient or group of patients (PD2009_060 Clinical Handover – Standard Key Principles) 15 The acronym ISBAR is a prompt for Introduction, Situation, Background, Assessment and Recommendation. The Australian Commission on Safety and Quality in Health Care has funded a trial in Hunter New England Health , using ISBAR to streamline the information provided to those taking over care and to keep the patient and family informed. 16 PD2009_060 Clinical Handover - Standard Key Principles http://www.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_060.pdf



20

Acute Coronary Syndrome (ACS)

Every day in NSW, adults present to emergency departments with symptoms of an Acute Coronary Syndrome (ACS). ACS includes cardiovascular conditions commonly known as heart attack (myocardial infarct) and unstable angina. Cardiovascular disease remains the leading cause of death in Australia17

(34 per cent of all deaths, according to Australian Bureau of Statistics 2007 data).

In February 2009, the CEC provided clinicians with a clinical focus report about ACS in NSW public hospitals. The focus report reflected analysis of IIMS and RCA data related to recognition and management of ACS. It found that there are a number of reasons why recommended treatment for this group of patients may be delayed – the primary one being recognition of ‘atypical’ symptoms. Not all patients experiencing an ACS complain of chest pain. In these cases, the recommended pathways for diagnosis (including ECG and blood tests) and time-critical anti-thrombolytic treatment may not be fully applied.

Clinical groups in both rural and metropolitan settings and NSW Health responded by

working together to improve the early recognition and treatment of ACS. Some of the strategies suggested have included setting-up networks to assist less-experienced or isolated doctors to read ECGs, educating emergency department staff in recognition of atypical symptoms and reinforcing the application of clinical guidelines for the management of ACS.

Healthcare Associated Infection (HAI)

Reducing the risk of healthcare associated infections (HAI) is an ongoing focus across Australia and internationally. The Australian Commission on Safety and Quality in Health Care (ACSQHC) nominated reduction of HAIs as a priority program for 2007-2010. It is working with States and Territories to improve awareness and response to potential infection of patients. NSW Health is participating in each of the five national strategies:

• national surveillance (centralised reporting) • building clinician capacity • national infection control guidelines • national hand hygiene project • antimicrobial stewardship program.

HAI incidents reported in IIMS include infections associated with venous access (cannula) and central lines, management of patients with MRSA, influenza and other infections which have the potential to be passed on to others. While the total number of HAIs reported for the period was 692, making it the thirteenth-highest PIT, there were two SAC1 incidents associated with patient deaths. Sepsis and HAI are also seen in clinical management incidents. The importance of maintaining clean (and where appropriate, sterile) environments and ensuring that the appropriate barriers and techniques are in place to prevent HAIs, continues to be a focus in all health services.

17 Heart Foundation media release 18 March 2009. http://www.heartfoundation.org.au/SiteCollectionDocuments/ABS%20Media%20Release.pdf

http://www.heartfoundation.org.au/SiteCollectionDocuments/ABS%20Media%20Release.pdf�


21

Antimicrobial stewardship focuses attention on reducing the chance of infectious agents becoming resistant to antimicrobial agents (such as antibiotics and disinfectants). In NSW the program will include a focus on Quality Use of Antibimicrobials in Intensive Care Units (QUAIC), so that the risk of infection for critically-ill patients is reduced. Successful antimicrobial stewardship requires a collaborative approach. A multi-disciplinary expert advisory group has been established. Updates on the progress of this work will be contained in future incident reports as well as at: http://www.cec.health.nsw.gov.au/programs/quaic.html More information about HAI can be found on the NSW Health18 and ACSQHC websites http://www.health.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-03#hai-about

Update on hand hygiene

Improving hand hygiene among health care workers is the single most effective way to reduce the risk of healthcare associated infections. ACSQHC has developed the National Hand Hygiene Initiative for achieving high compliance with hand hygiene, as defined by World Health Organization (WHO) standards. The Clinical Excellence Commission is leading the implementation of the program in NSW.

In May 2009, World Hand Hygiene Day was celebrated with activities and training in hospitals across the State and a marquee in Martin Place, Sydney, promoting the use of alcohol-based hand rubs. A range of telephone messages-on-hold promoting the importance of hand hygiene were provided for use in hospitals across the State. These, along with further information about hand hygiene, can be downloaded from the CEC website.

http://www.cec.health.nsw.gov.au/programs/hand-hygiene.html

Update on CLAB

Previous reports have discussed the CEC project to reduce the incidence of Central Line Associated Bacteraemia (CLAB) in patients in intensive care units. The reduced rate of infection previously reported was sustained in the current reporting period. The CEC project has now concluded and the surveillance of CLABs in ICUs has been established as part of routine reporting of HAIs to NSW Health. The project’s success has been recognised internationally.

Other Learnings

Understanding the underlying causes of incidents

Root cause analysis (RCA) identifies factors which may have contributed to serious (SAC1) clinical incidents, in an effort to prevent them in future. The NSW RCA Review Committee checks all clinical management incident reports, so that emerging themes and underlying issues can be identified and highlighted for action. In addition to the IIMS classification sets, it looks at underlying factors for patients, staff and the system.

18 Infection Control Policy: Prevention & Management of Multi-Resistant Organisms (MRO) http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_084.pdf Infection Control Policy http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf

http://www.cec.health.nsw.gov.au/programs/quaic.html�

http://www.health.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-03#hai-about�

http://www.cec.health.nsw.gov.au/programs/hand-hygiene.html�




22

In this context “system” refers to co-ordination of care, routine treatment processes and the application of best practice guidelines and policy. All are essential for the provision of quality care to the right patient, at the right time and in the best possible location.

System factors were the most common underlying contribution to serious clinical incidents. More than one system factor was identified in 80 per cent of the RCAs reviewed. Nearly one-third related to communication between staff, including when care is being handed over to another shift or speciality team. Availability, awareness and usefulness of policy, procedures and guidelines was the second highest factor (23 per cent). RCAs also identified that workforce issues, including skill mix, education and orientation, can impact on the capacity of staff to provide quality care (nine per cent). Care planning was the next-highest category identified.

The term “human factors” refers to types of errors made by doctors, nurses and other health care staff. These are broadly categorised into:

cognitive errors, related to interpretation of information and decision-making, e.g., assuming that because it is raining outside, it will be cold

skill-based errors, where a step in a familiar task is inadvertently omitted, e.g., forgetting to turn off the oven after removing food19

(rule) violations, e.g., crossing a clear road against the don’t walk signal, or exceeding the speed limit by a few kilometres per hour. We know we shouldn’t, but may do so, in order to reduce the time it takes to get the end point.

One hundred and one of the 209 RCAs reviewed by the committee identified human factors. Cognitive errors were the most common (57 per cent), followed by violations of policy/procedures (22 per cent) and skill-based errors (16 per cent).

Cognitive errors can occur because information is incomplete or misinterpreted. They are also common where there are many factors to consider and decisions need to be made quickly. The increasing complexity of patients’ conditions requires the assimilation of much information when deciding on the most appropriate treatment. The role of cognitive factors in diagnostic error has also been explored internationally 20 21

RCA reviews also attempt to determine whether particular groups of patients are more likely to be involved in a serious incident (“patient factors”). The most common largely represent groups with higher rates of admission to health care services – i.e., those who have chronic conditions such as diabetes, heart or renal failure, or cancer and those aged over 75. Other

and is sometimes referred to as premature closure (the failure to consider reasonable alternatives after an initial diagnosis has been reached).

In health care, violations generally occur because staff are trying to expedite care of patients in high-workload areas. There is no intention of causing harm.

Skill-based errors are often associated with fatigue, distractions and interruptions. They include slips and lapses of attention and memory that everyone experiences every day.

19 This is different from making an error because you have not yet acquired the necessary level of skill. The RCA committee bases its classification set on that used in aviation human factors analysis. 20 Graber M, Franklin N &Gordon R (2005) Diagnostic Error in Internal Medicine, Archives of Internal Medicine 2005;165:1493-1499 21 Singh H, Petersen LA & Thomas EJ (2006), Understanding diagnostic errors in medicine: a lesson from aviation. Quality & Safety in Health Care 2006;15:159-164


23

factors, such as having English as a second language, obesity, impaired cognitive functioning due to mental illness, dementia, confusion or delirium were also identified.

While it is important to recognise and manage increased risk for older, sicker patients, it is equally important to be alert to potential risks for all patients in the health system.

Sharing lessons learned with clinical staff

Analysis of IIMS and RCA data is of no benefit if the findings are not shared with those who care for patients every day. In addition to this bi-annual report, the CEC shares in a number of ways, including:

• annual IIMS reports to each health service, including the Children’s Hospital at Westmead, Ambulance NSW and Justice Health

• monthly feedback to each director of clinical governance from the RCA Review Committee

• clinical focus reports, highlighting emerging themes • liaison with clinical interest groups, the Greater Metropolitan Clinical Taskforce, NSW

Health taskforces and committees • other clinical quality forums.

Provision of clinical focus reports to the NSW Health Reportable Incident Review Committee has also been effective in prompting and informing safety alerts and reviews of care processes. During the January – June 2009 period, these reports provided information on:

• management of acute coronary syndrome

• patient falls

• sedation/excess sedation as an adverse outcome

• management of tracheostomy and tracheostomy emergencies.

These reports are also provided to health service staff.

The Safety Alert Broadcast System

NSW Health has developed the Safety Alert Broadcast System (SABS) to relay concerns as quickly as possible. This provides health services with early warnings about safety issues and indicates who is responsible for taking action. SABs are developed in response to risks identified in clinical incidents, RCAs, clinical focus reports, complaints and international reports and alerts. To ensure their accuracy and effectiveness, alerts and notices are written in consultation with experienced clinicians. Twelve SABs were released between January and June 2009.


24

There are three levels of warning.

Safety Alert: Requires immediate action, designates who is responsible and calls for mandatory reporting of the steps taken to address the risk.

Safety Notice: Alerts designated managers to important issues. They must review or develop processes and protocols to ensure that the issue is managed for any safety risk.

Safety Information: Provides information on safety issues.

Information about these can be viewed on the SABS website at: www.health.nsw.gov.au/quality/sabs/index.html

Lessons Learned

NSW Health also provides staff with examples of actions taken in response to clinical incidents, so that action can be taken to reduce the chance of similar incidents occurring elsewhere. These case studies are grouped to assist staff to learn about particular types of risks to patients under their care. The Lessons Learned site is available to all staff through the NSW Health intranet.

In conclusion We are committed to providing ongoing reports on incidents within the NSW health system. We look forward to providing you with more information on the progress of changes made in response to this analysis in our next report. We will continue to look. We continually learn and we again commit to continuous action in clinical practice improvement.

Professor Clifford Hughes, AO Professor Debora Picone, AM Chief Executive Officer Director-General

Clinical Excellence Commission NSW Health

http://www.health.nsw.gov.au/quality/sabs/index.html�


25

Data Analysis Dashboard A data dashboard is a concise way of representing numbers and types of incident notifications. Using the same format in future incident reports will assist the reader in comparing these data sets over time. Top Three Principal Incidents Types by SAC Rating

SAC 1

SAC 2

SAC 3

SAC 4

No SAC

Falls Medication/IV Fluid Clinical Management

Falls Falls are the most commonly reported clinical incident in IIMS. They happen most

frequently among patients aged 75 or older. People who fall in hospital often have more than one chronic condition, may be taking many medications and may be frail.

In the reporting period 13,317 notifications identified a fall as the PIT. Twenty-six were classified as SAC1, compared with 16 in the previous six months. The rate of 4.30

falls per 1,000 (inpatient) bed days reflects best-practice figures in the international literature, which cite an average of five falls per 1,000 bed days**. Falls were the most

frequently reported incident in aged care, general medical and rehabilitation units.

Age of patients in fall incident notifications (all SAC ratings)

Location of patients in fall incident notifications (all SAC ratings) Time of fall (all SAC ratings) **Oliver, D (2007) Preventing falls and fall injuries in hospital: a major risk management challenge. Clinical Risk 2007 13 173-178

2698

2344

1256

621

586

460

358

337

322

308

284

223

213

213

203

148

144

131

127

109

0 500 1000 1500 2000 2500 3000

Aged Care - Geriatrics

Medicine - General

Rehabilitation

Mental Health - Inpatient

Aged Care - Psychogeriatrics

Surgical - Orthopaedics

Surgical - General

Neurology

Cardiology

Palliative Care

Other

Medical Oncology

Physiotherapy

Respiratory medicine

Emergency medicine

Renal medicine

Neurosurgery

General practice

Gastroenterology

Haematology


26

Data Analysis Dashboard (cont) Fall incident notifications (all SAC ratings) January 2007 – June 2009

SAC1 Falls Clinical Area under which SAC1 falls were notified

Clinical Area Count

Medicine/endocrinology 7

Emergency department 6

Aged care/rehabilitation/palliative care 5

Surgery-orthopaedic 3

Surgery-other 1

Cariology/respiratory medicine 1

Cancer care 1

Gastroenterology 1

ICU/HDU 1

TOTAL 26

Patient factors identified in SAC1 Fall incidents

Acting to reduce falls and fall injury A number of initiatives are occurring across the state. These include:

Issue What is being done

Ensuring all staff understand falls risk Increasing staff in-services on falls and implementing self-directed learning packages which staff must complete

Patients fall when trying to get to/use the toilet

Implementing regular nursing rounds to assist patients with toileting

Increasing patients’ and families’ awareness of falls risk

Providing falls prevention information and letting patients/families know when a patient is at risk of falling

Reducing falls risk for patients with an altered mental state (e.g., confusion, delirium or dementia)

Staff training and patient supervision programs

Reducing risk for patients who are more likely to fall

Targeted assessments of mobility and transfers (sit-stand, +/- aids) Increasing medication reviews and staff awareness through education

What to do if a patient does fall Implementation of the CEC Post-fall Management Guide


27

Medication/IV fluid Medication or intravenous fluid incidents continue to be the second-highest type of incident reported. Four of the 10,924 reported in the current period were SAC1. In the previous reporting period there were 10,197, including two SAC1s.

Medications associated with incident notifications - top 10

Intended effect of top 10 medication agents involved in incidents

Agent Intended effect

Paracetamol Pain relief, reducing fever

Aspirin Pain relief, reducing fever and inflammation

Oxycodone, morphine, fentanyl Opiate-based pain relief

Methadone hydrochloride Pain relief, management of drug dependence

Warfarin sodium, heparin, enoxoparin sodium (clexane)

Antithrombolytic (anti-clotting) agents

Insulin Synthetic hormone used to manage diabetes

Data Analysis Dashboard (cont) Time of medications incidents

Stage of medication delivery where incident was reported to have occurred

0 1000 2000 3000 4000 5000

Administration

Prescribing problem

Dispensing problem

Other

Delivery problem

Narcotic/controlled drug discrepancy

Storage/wastage/security

Supply/ordering problem

Undesired drug effect during …

Presentation

541

445

385

301

267

262

260

229

182

180

0 100 200 300 400 500 600

Morphine

Oxycodone

Paracetamol

Insulin

Fentanyl

Methadone hydrochloride

Warfarin sodium

Heparin

Frusemide

Enoxaparin sodium

0

200

400

600

800

1000

1200

1400

00:0

0 to

00

:59

01:0

0 to

01

:59

02:0

0 to

02

:59

03:0

0 to

03

:59

04:0

0 to

04

:59

05:0

0 to

05

:59

06:0

0 to

06

:59

07:0

0 to

07

:59

08:0

0 to

08

:59

09:0

0 to

09

:59

10:0

0 to

10

:59

11:0

0 to

11

:59

12:0

0 to

12

:59

13:0

0 to

13

:59

14:0

0 to

14

:59

15:0

0 to

15

:59

16:0

0 to

16

:59

17:0

0 to

17

:59

18:0

0 to

18

:59

19:0

0 to

19

:59

20:0

0 to

20

:59

21:0

0 to

21

:59

22:0

0 to

22

:59

23:0

0 to

23

:59

Unkn

own

time

Num

ber


28

Clinical Management

Clinical management is the third-highest category of notifications in IIMS, but contains the highest number of SAC1 incidents.

From January – June 2009, 9,247 clinical management notifications were received, compared with 8,515 in the previous period. This is an 8.5 per cent increase. The

high percentage (7.1 per cent) of both SAC1 and SAC2 incidents in this PIT reflects the increasingly complexity of clinical care.

Clinical management SAC1 incidents by specific issue

Category of Care 2007 2008 2009

Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun

Diagnosis missed or delayed 34 37 17 35 29

Complication 21 15 9 14 17

Investigations delayed or results not reviewed

3 5 1 4 5

Observations not performed/significance not recognised

12 20 14 5 2

Transfer of care – delayed or inadequate preparation

4 2 3 3 9

Inter-hospital transfer processes 1 2 1 3 1

Treatment delayed and/or inadequate 16 33 23 37 39

Retained material following surgery 6 9 10 24 13

Identification – wrong patient/site/procedure

40 42 61* 44 56

*includes near-miss incidents

Data Analysis Dashboard (cont) Location of Wrong Patient, Site, Procedure Incidents

Department 2007 2008 2009

Jan-Jun Jul-Dec Jan-Jun Jul-Dec Jan-Jun

Operating Suite 3 7 11 9 12

Dental 1 0 2 1 2

Imaging/Nuclear Medicine 32 29 31 24 33

Radiotherapy 2 0 0 0 0

Wards & other areas 7 5 17 10 9

TOTAL 45 42 61* 44 56

SAC1 RCAs related to Falls, Clinical Management, Blood/Blood Products and Medication/IV Fluids (n=209) were reviewed by the State RCA Review Committee to determine underlying system factors. The following were identified. System factors identified in SAC1 incidents Jan-Jun 2009 (n=209

0 50 100 150 200

communicationpolicy, procedure, guidelines

workforcecare planning

risk recognition/managementaccess

supervisionequipmentteamwork

transfer of careenvironmental factors

use of eMR


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APPENDIX 1: Managing Clinical Incidents in the NSW Health System SAC1 - Extreme risk

SAC2 - High risk SAC3 & 4 – Medium or low risk

Immediate actions

Immediate threats to safety removed. IIMS notification made. Area health services (AHS) chief executive informed. Department of Health (DoH) notified via Reportable Incident Brief (RIB) for Statewide risk assessment.

Immediate threats to safety removed. IIMS notification made. Senior management notified. DoH notified via RIB of incidents with Statewide implications.

Immediate threats to safety removed. IIMS notification made. Manager notified.

Investigation root cause analysis (RCA) investigation is completed by the AHS and sent to the DoH within 70 days.

Detailed investigation overseen by clinical governance unit at AHS level.

Manager reviews and determines actions required.

Analysis and aggregation of findings

State level – thematic analysis of RCAs undertaken and reported monthly to the Reportable Incident Review Committee (RIRC). AHS level

– peak quality committees and lead clinicians informed.

AHS aggregated data used to determine local actions.

Data is aggregated and regularly discussed with clinical team. Risks which have broader implications are fed-up via management and clinical stream processes.

Actions in response to identified risks

State level - Actions to address identified risks are determined by RIRC and undertaken by relevant organisation (DoH, CEC). AHS level

– RCA recommendations implemented.

AHS level –Recommendations from detailed investigations actioned.

Actions managed at local level.

Feedback Information about State level projects / actions is given via monthly meetings with directors of clinical governance. SABS and lessons learned website, six-monthly incident report. AHS processes to feedback to patients/ families via Open Disclosure and to staff and clinical teams via local processes.

Information about State-level projects/actions is given via monthly meetings with directors of clinical governance, SAB and lessons learned website, six-monthly incident report. AHS processes to feedback to patients and families via Open Disclosure and to staff and clinical teams via local processes.

Information about State-level projects/actions is given via monthly meetings with directors of clinical governance. SAB and lessons learned website, six-monthly incident report. AHS processes to feedback to patients and families via Open Disclosure and to staff and clinical teams via local processes.

AHS - Area health service DoH - Department of Health RIB - Reportable Incident Brief RIRC - Reportable Incident Review Committee SABS – Safety Alert Broadcast System

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APPENDIX 2: Principal Incident Type Definitions and Data Accidents/Occupational Health and Safety

This is used to classify incidents related to accidents, occupational health and safety, or the physical environment and staff incidents. Examples are a needle stick injury, exposure to a hazardous substance, a staff member sustains a burn after spilling a hot drink over his arm, a wet or slippery floor surface.

Aggression – Aggressor

This is used to classify the details of the aggressive incident, in the context of the aggressor. Examples are a patient punching another person, a person making physical or verbal threats.

Aggression – Victim

This is used to classify any harm to the victim of an aggressive episode. Examples are a patient being punched by another individual, a victim of a physical or verbal threat.

Anaesthesia

This is used to classify the details of incidents related to anaesthesia delivery. This classification does not capture information related to surgical complications or incidents. These need to be reported separately.

Behaviour/Human Performance

This is used to classify the details of behaviour or human performance incidents. Examples are a patient exhibiting self-harming behaviour, a staff member behaving in a rude or hostile manner.

Blood/Blood Products

This is used to classify the details of incidents related to blood /blood product transfusion processes, dispensing or quality problems. Examples are a patient suffers an anaphylactic reaction to a blood transfusion, a blood unit is mislabelled, blood is stored at the incorrect temperature, incorrect blood pack is dispensed from transfusion service.

Buildings/Fittings/Fixtures/Surrounds

This is used to classify the details directly related to a building, including fittings within, a building, the fixtures attached and the external surrounds of a building. Examples are poorly designed building/room for its intended purpose, leaky plumbing, loose or insecurely fixed wall mounted appliance, cracked or uneven pathways, power failure.

Clinical Management

This is used to classify the details related to the clinical management of a patient. This includes diagnosis, treatment planning and delivery and ensuring the correct identification of each patient and procedure. Examples are unintended injury during a medical/surgical procedure, procedure performed on the wrong body part or side, delay in diagnosis of patient's condition.

Complaints

This is used if a consumer expressed dissatisfaction about health care services. Examples include a complaint about the care provided or the manner in which it is delivered.

Documentation

This is used to classify the details of an incident involving a problem with any written, typed, drawn, stamped or printed text/information and/or any document into which it has been

31

entered. Examples are a patient's medication chart is filed into another patient's medical record, a treatment order is ambiguous or difficult to read, incorrectly labelled specimens.

Falls

This is used to classify details related to a fall. Examples are a patient found on the floor is suspected of having fallen, a disorientated patient fell after forgetting to use his walking frame.

Hospital Acquired Infection/Infestation

This is used to classify the details of infections or infestation acquired during hospitalisation. Examples are a post-operative wound infection, an infected IV (intra-venous) cannula site.

Medical Devices/Equipment/Property

This is used to classify the details directly related to medical devices, equipment or property. Examples are routine maintenance not performed on an autoclave, no diathermy earthing plates available for a theatre procedure, a damaged or faulty patient lifter.

Medication/IV fluids

This is used to classify the details related to medication or intravenous fluid incidents. Examples are medication prescribing errors, incorrect intravenous fluid infusion rates.

Nutrition

This is used to classify the details of nutrition incidents. Examples are a diabetic patient received a non-diabetic meal, the wrong TPN (Total Parenteral Nutrition) formula was infused, a patient's naso-gastric feed was given at 80 mls/hr instead of 40 mls/hr.

Organisation Management/Services

This is used to classify the details of any incident involving the provision of patient, staff and visitor services or the organisational management of the health care institution. Examples are no hospital beds available, inadequate staff supervision, insufficient staff for workload, inadequate staff facilities, no after-hours kitchen service available.

Oxygen/Gases/Vapours

This is used to classify the details of incidents involving both therapeutic and non-therapeutic use of oxygen and/or other gas. Examples are oxygen administered at four litres per minute when it should have been eight, medical air administered instead of oxygen.

Pathology/Laboratory

This is used to describe issues associated with the collection, transport and processing of specimens.

Pressure Ulcer

This is used to classify details of either new pressure ulcers or the worsening of pre-existing pressure ulcers which occur during clinical care. An example is when a bed-bound patient develops a pressure area.

Security

This is used to classify the details of incidents directly related to the security of the organisation. Examples are theft of personal property, bomb scare.

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Incidents Reported in IIMS by Principal Incident Type

(Accurate at time of extraction 4 August 2009)

Principal Incident Type Number

Fall 13,317

Medication/IV fluid 10,924

Clinical management 9,247

Aggression-aggressor 5,808

Behaviour/human performance 4,758

Pressure ulcer 4,205

Documentation 4,088

Accident/occupational health and safety 2,583

Organisation management/service 1,913

Medical device/equipment/property 1,639

Blood/blood product 810

Aggression-victim 752

Health care associated infection/infestation 692

Complaint 427

Nutrition 412

Pathology laboratory 345

Security 224

Building/fittings/fixtures/surrounds 180

Oxygen/gas/vapour 45

TOTAL 62,369

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APPENDIX 3: Definitions

IIMS Incident Information Management System. An on-line incident reporting and management system developed in Australia for NSW Health.

Incident Any unplanned event resulting in, or having the potential to result in harm to a patient.

Incident management

The cycle of activities required to recognise, report, understand and reduce the risk of unplanned events occurring. In the health system, feedback to the notifier and sharing of learnings are essential components of this cycle.

Near-miss An unplanned event that did not result in injury, illness, or damage - but had the potential to do so. A break in the chain of events prevented harm, either due to staff recognition and action, or a fortuitous event.

Notification The initial report within IIMS that an incident or near-miss may have occurred. All staff are required to report incidents in IIMS and must complete the mandatory fields within the system. Notifications can be anonymous and reflect the information known by the reporter at the time.

Peri-natal The period shortly before, during and after the birth of a baby.

Principal Incident Type

The classification system within IIMS which assists the incident reporter to describe the incident. The term is often abbreviated to PIT.

RIB Reportable Incident Brief. A document used to notify NSW Health of a reportable incident. RIBs are subject to statutory privilege under section 23 of the Health Administration Act. For more information, see PD2006_058 Authorised Research and Investigation under the Health Administration Act 1982 and the Incident Management Policy Directive.

SAC Severity Assessment Code. The system by which the severity of an incident is rated and the required response is directed across NSW Health services. More information is contained in the Incident Management Policy Directive: http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_061.pdf


34

Reference List Reports and Policies

1. Department of Health and Human Services USA (2008); Adverse events in hospitals: case study of incidence among Medicare beneficiaries in two selected Counties. (December 2008) OEI-06-08-00220

2. Pennsylvania Patient Safety Authority 2008 Annual Report, released April 2009 http://www.psa.state.pa.us/PatientSafetyAuthority/Documents/annual_report_2008.pdf

3. Caring Together – The Health Action Plan for NSW http://www.health.nsw.gov.au/pubs/2009/caring_together_hap.html

4. Council of the European Union (2009). Council Recommendation on Patient Safety, including the prevention and control of healthcare associated infection; 2947th Employment, Social Policy, Health and Consumer Affairs Council Meeting, Luxembourg, June 2009.

5. Australian Heart Foundation; media release 18 March 2009. http://www.heartfoundation.org.au/SiteCollectionDocuments/ABS%20Media%20Release.pdf

6. National Patient Safety Authority UK (2008) Reducing risk of overdose with midazolam injections in adults. NPSA December 2008 NPSA/2008/RRR011 http://www.nrls.npsa.nhs.uk/resources/?entryid45=59896&q=0%c2%acmidazolam%c2%ac

7. NSW Health Policy Directive: Patient Safety and Clinical Quality Program. PD2005_608 http://www.health.nsw.gov.au/policies/pd/2005/pdf/PD2005_608.pdf

8. NSW Health Policy Directive: Incident Management. PD 2007_061 http://www.health.nsw.gov.au/policies/pd/2007/PD2007_061.html

9. NSW Health Policy Directive: Clinical Handover - Standard Key Principles. PD2009_060 http://www.health.nsw.gov.au/policies/pd/2009/pdf/PD2009_060.pdf

10. NSW Health Policy Directive: Infection Control Policy: Prevention & Management of Multi-Resistant Organisms (MRO). PD2007_084 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_084.pdf

11. NSW Health Policy Directive: Infection Control Policy. PD 2007_036 http://www.health.nsw.gov.au/policies/pd/2007/pdf/PD2007_036.pdf

Journal Articles

1. Berntsen KJ (2006) Implementation of patient centeredness to enhance patient safety. Journal of Nursing Care Quality 21(1) 15-19

2. Bo S. Valpreda S. Scaglione L. Boscolo D. Piobbici M. Bo M. Ciccone G. (2007) Implementing hospital guidelines improves warfarin use in non-valvular atrial fibrillation: a before-after study. BMC Public Health. 7:203, 2007

3. Graber M, Franklin N & Gordon R (2005) Diagnostic Error in Internal Medicine, Archives of Internal Medicine 2005;165:1493-1499

4. McCauley K & Irwin RS (2006) Changing the work environment in ICUs to achieve patient-focused care. Chest 2006;130:1571-1578

5. Oliver, D (2007) Preventing falls and fall injuries in hospital: a major risk management challenge. Clinical Risk 2007 13 173-178

6. Schumock GT, Blackburn JC, Nutescu EA, Walton SM, Finley JM, Lewis RK (2004) Impact of prescribing guidelines for inpatient anticoagulation. Annals of Pharmacotherapy. 38(10):1570-5, 2004 Oct

7. Singh H, Petersen LA & Thomas EJ (2006), Understanding diagnostic errors in medicine: a lesson from aviation. Quality & Safety in Health Care 2006;15:159-164


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