31 January 2005

Patient safety report released

NSW Health Minister Morris Iemma today released the first report on incident management in public hospitals as part of the Carr Government’s detailed plans to improve patient safety.

“The NSW Government is committed to a culture of open disclosure in our public hospitals,” Mr Iemma said.

“I want doctors and nurses to feel confident that they can report incidents and that they will be reviewed and that lessons are learned and implemented as part of the Carr Government’s determination to drive further improvement.

“The Patient Safety and Clinical Quality Program Report and the data I am releasing today will form part of a National Report on adverse incidents in public hospitals to be released towards the end of this year.

“I am confident that NSW has the best system for reporting and investigating incidents in our hospitals in Australia,” Mr Iemma said.

The Patient Safety report identifies 31 incidents in NSW public hospitals known as “sentinel events” which are judged against a set of nationally defined criteria.

During this time, there were 1.5 million patient admissions and more than 25 million outpatient services provided in NSW public hospitals.

The only comparable figure currently available is for Victoria which recorded 30 sentinel events in 2003/04.

The report goes further than any other state, by also measuring all Category 1 incidents which covers events such as clinical management problems, falls and wrong patient/site/procedure incidents.

“The Carr Government has established and funded the Clinical Excellence Commission (CEC) to oversee the reporting of incidents and to ensure that systems are improved where faults are identified.

“The Government’s aim is to make our hospitals safer. To achieve this, we must have quality information on what is going wrong and why,” Mr Iemma said.

The Carr Government has established the Patient Safety and Clinical Quality program, which includes the establishment of the Clinical Excellence Commission and individual clinical governance units in Area Health Services.

“To prevent mistakes being repeated, it is vital to capture information about them.

NSW has adopted a process developed in the United States to undertake Root Cause Analysis (RCA) on all Category 1 incidents.This RCA process determines what happened, why it happened and the underlying causes.The RCA process has already led to the implementation of clinical improvements including initiatives to reduce the number of falls in hospitals.

These include:

• The use of arm bands on high risk patients;
• Establishing on site ‘Fall Reduction Teams’;
• Eliminating hazards such as high beds and lowered bed rails with high risk patients.

These policies have already been introduced at Lithgow, St George, Queanbeyan, Coffs Harbour and Orange Base hospitals. A state wide policy is being implemented.

A policy that deals with ‘wrong patient/wrong site/wrong procedures’ has also been introduced that sets out protocols for:

• Procedure consent;
• Patient identification;
• Marking the site of any invasive procedure; and
• Confirming the site.

Minister Iemma said the Medical Registration Board and the reformed Health Care Complaints Commission continued to provide effective investigative bodies for cases of individual malpractice or negligence.

“With the release of today’s report, I am confident that NSW has the most transparent system of reporting and investigation of medical incidents in the country,” Mr Iemma said.

Related links:

For a range of health information, go online to www.health.nsw.gov.au