Come and hear how from the expert! (Event details included below)
Patients within the Queensland public hospital system enjoy health services that, on the whole, are delivered in a safe and effective manner. However, as in any health system in the world, clinical incidents do occasionally occur. The challenge is learning from them, by building a safety culture in health care. This builds trust in the front line staff who report these incidents and in turn, builds trust in the community.
In January 2011 Dr John Wakefield, Executive Director, Patient Safety and Quality Improvement Service (Service), released the fourth report on Clinical Incidents and Sentinel Events in the Queensland Public Health System 2008/09, "Patient Safety: From Learning to Action IV" (report).
Being the fourth in the series, the report provided comparative data on the voluntary reporting of clinical incidents by front line staff. The most significant feature is the 25% increase in reporting from the previous year; amounting to a 115% increase over the previous four year period. This represents a fundamental cultural shift in the manner in which front line staff report incidents.
At first blush, this 25% increase could be interpreted as a sign of worsening patient safety within the Queensland Public System. On the contrary, analysis of the data reveals that increased reporting is directly correlated with a better safety culture and better patient outcome. The 25% increase in reporting comprised largely of near misses, which was the original intent of raising awareness of the reportability of incidents, thereby capturing more incidents for analysis. This in turn helps assist in better understanding the root cause of incidents and the implementation of changes aimed at improving safety.
A number of initiatives by the Service have been directly responsible for building a culture of safety within the Queensland Health Public System. These tools, fortified by comprehensive training, include but are not limited to:
- comprehensive clinical incident reporting systems, such as Root Cause Analysis, Human Error and Patient Safety Analysis, PRIME Clinical Incident, and clinical reviews; and
- Open Disclosure.
These initiatives encourage openness and transparency, in a 'just' culture, where staff are not inappropriately blamed when incidents occur with the aim of staff logging all incidents with a view to examining the circumstances in which they occur and ascertaining which ones are preventable. Trends and common areas can then be targeted by the development of tools, and training to minimise occurrence. Staff feel their concerns are being meaningfully addressed, which in turn encourages a culture of reporting.
It is noteworthy that of the 71,305 clinical incidents reported, 78% were not associated with any patient harm.
A clinical incident is not necessarily associated with a mistake or an error, and rarely leads to patient harm. Only a small percentage of incidents have a serious outcome such as death or permanent disability. When front line staff are encouraged to report them all, something can be done about finding ones that are preventable.
One of the key changes of reporting incidents and events was the move away from the traditional "medical error" approach, to one focused on reporting all outcomes of care that were unexpected from the staff, patient and families perspective.
To effect this, the definition of "clinical incident" was changed from the 2006 definition of "death or permanent loss of function unrelated to the natural cause of the underlying condition", to those circumstances where the health care outcome was not reasonably expected by the patient and their family, or by the clinicians treating the patient.
The enlargement of the definition is reflected in the more serious events that are categorised by use of the Severity Assessment Code (SAC). These are based upon the seriousness of the consequences to the patient as follows:
SAC 1 event:
SAC 2 event:
SAC 3 event:
Analysis revealed that the 71,305 reported incidents were made up as follows:
- SAC 1 0.45% (318 incidents)
- SAC 2 4.65% (3,314 incidents)
- SAC 3 94.91% (67,673 incidents).
The most common incidents related to falls, pressure areas and deviations from planned care.
Feedback of incidents is provided to staff by a number of mechanisms, including the Services newsletter, safety alerts/notices/communiqués and training programmes.
Consistent with the trends, existing safety and quality programmes of the Service includes falls programme, medication safety, open disclosure programme, pressure ulcer prevention programme and State-wide clinical networks.
New and emerging strategies the Service is working on include clinical handover programme, medical device safety programme and recognition and management of the deteriorating patient programme.
Prior to 2005, neither a robust reporting culture nor the tools to support it existed in Queensland Health. Subsequently, through the work of the Service, this has dramatically changed, leading to the development of a more reliable and safer health service.
Invitation
Dr John Wakefield, recipient of the recent Australia Day Awards for Queensland Public Service in relation to patient safety and high quality service delivery, will provide a presentation on Thursday 26 May at 5.30pm on the challenges of driving large scale reform and improvement in patient safety, what has been learned so far and what the future holds.
For further information or register your attendance at Dr John Wakefield's presentation, please visit CGW Events.
If you would like to discuss this alert in more detail, please contact Carol Lee on 07 3231 2935.
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