JMO Orientation

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JMO Orientation

• Quality and Patient Safety
• Whats it all about?

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Whos Responsible

• Quality is everyones responsibility
• Quality in health is doing the right thing, the
  first time, in the right way, in the right time.

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What is Clinical Governance?

• Clinical Governance is based on the principle
  that all of us, clinicians and managers alike,
  are jointly accountable for quality of patient
  care and standards of care delivery. Clinical
  Governance is the framework by which this
  accountability is ensured and demonstrated.
• The Australian Council on Healthcare Standards
  (ACHS) defines this as the system by which the
  governing body, managers and clinicians share
  responsibility and are held accountable for
  patient care, minimising risks to consumers and
  for continuously monitoring and improving the
  quality of clinical care.

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Patient Safety What is the issue?

• Each year in Australia there are
• 470,00 admissions associated with an Adverse
  Event
• 18,000 deaths
• 50,000 permanent disabilities
• 3.3 million bed days lost
• 800m spent in direct medical costs
• The Quality in Australian Healthcare Study 1995

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Incident
An incident is an unexpected outcome of care or
service delivery process that could have or did
lead to a patient being harmed and/or a
complaint, loss or damage
Adverse Event

• An adverse event is an incident in which actual
  harm resulted to a person receiving health care

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Near Miss

• Incident which almost happened but the situation
  was corrected before any harm, loss or damage
  occurred
• (for example wrong medication prescribed by
  doctor but alerted before dispensed by pharmacist
  or administered by nurse)

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Incident Information Management System (IIMS)

• All incidents near misses
• Unplanned event resulting in or with potential
  for injury, illness, damage (eg falls, medication
  error, staff injury, security risk, wound
  infection)
• Document
• Review
• Actions
• Outcome
• Recommendations
• Provide reports data

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Severity Assessment Code (SAC)

• All notified incidents are assessed according to
  their risk rating
• Risk is calculated by multiplying the likelihood
  of an event occurring against the actual
  consequence or outcome
• Consequences x Likelihood Risk

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Initial SAC
Consequences - actual consequences / outcome of
the incident (not what could have happened)
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Likelihood the chance that this or a similar
incident / outcome could recur in this or
similar circumstances (determine the likelihood
of recurrence of this incident)
Apply the consequences eg major, minor and the
likelihood eg likely, possible, to the SAC matrix
to determine a SAC score.
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SAC Matrix
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Clinical example of the SAC matrix
A patient in an medical ward slipped in the
shower bruised their hip, was seen by RMO
Xrayed consequences minor (review evaluation,
additional investigation) likelihood likely
(may occur several times a year),
If they fractured their hip, the consequences
would change to moderate (surgical intervention
or increased length of stay) likelihood
possible (may recur every 1-2 years).
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You can access e-IIMS Forms here
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Select Hunter New England
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• Choose
• Clinical
• Complaints
• Property, security, hazard or
• Staff, visitor, contractor
• (Read the definitions provided)

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Incident location is the department which will
primarily be responsible for managing the
incident. It is a mandatory field ?(must be
completed)
Click on the sign next to HNE Area Health
Service to expand the tree
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Drill down the tree by clicking on each sign
to expand the facility to services / departments
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Services / departments can be expanded further by
clicking on the sign until you reach ward /
unit level ( egobstetrics)
It is important to select the correct unit so the
incident is directed to the correct manager /
department for review and follow up
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Highlight the selected ward / unit
Place of incident is a more precise location eg
bathroom, car park
Incident date is a mandatory field ?(must be
completed)
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The minimum data fields must be completed in
order for the notification to be saved and an
IIMS number generated

• Incident type(s)
• Principal incident type
• Incident description
• are also mandatory fields ?(must be completed)

In free text boxes never use patient or staff
names, only designation eg RN, RMO, patient A
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Try to complete as many fields as possible and
provide information to assist in review and
management of an incident
Notification can be anonymous
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• For staff incidents
• Include your employee number
• First last names
• are also mandatory fields ?(must be completed)

• Ask your manager to print out 2 copies
• Keep 1 copy for your record

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Click save. You will be provided with an IIMS
number. Write this down. If it is a patient
incident document the incident, action taken etc
in the patient medical record and include the
IIMS number
The department manager of the incident location
will receive an automatic e-mail
notification. Advise the department manager/s of
your IIMS notification as matter of courtesy,
particularly if another department is involved.
This allows early investigation action
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• The SAC matrix is available in the IIMS
  electronic notification
• Definitions of the likelihood and consequences
  are included in the rules in the IIMS data base
  
• A hard copy is provided in the IIMS resource
  folder

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• Advise your manager / after hours supervisor of
  all incidents, particularly those which are
  serious (eg SAC 1 or 2). Your initial SAC rating
  of the incident will provide this information
• Severity Assessment Code (SAC)
• Refer to the rules in the SAC matrix to
  determine
• consequence (eg serious, minor)
• likelihood (eg frequent, rare)

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Serious Adverse Events

• SAC 1 incidents are investigated by a process
  called Root Cause Analysis (RCA)
• A Root Cause Analysis is a systematic process for
  investigating adverse events by identifying
  system failures in order to prevent recurrence
• A root cause (or latent failure) should actually
  say something about the organisations management
  system

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Adverse Events Principles of Investigation

• Final event tip of iceberg
• Latent events precede the active error
• No blame, just approach to staff involved
• Open disclosure to stakeholders including patient
  and carers
• Focus is on prevention of reoccurrence

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Open Disclosure

• Health care workers are expected to disclose to
  patients/carers when things go wrong
• Open Disclosure is NOT an admission of guilt.
  Patients and their families want and deserve an
  apology when the outcome is not as expected.
• Document in the notes what is said and by whom.
  This to ensure that if the patient or carer is
  non-attentive there is an accurate record of the
  events that occurred

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Open Disclosure

• Think about how you would tell a patient that the
  results of their tests were not available because
  the documentation was incorrect.
• Due to this error / oversight the patient will
  need to wait another 24hrs to find out if their
  diagnosis is cancer or not!

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Policy Compliance

• Clinical Governance is also about ensuring that
  when a policy is released that there is a plan in
  place for the AHS to ensure implementation.
• Compliance with the Correct Patient, Correct Site
  and Correct Procedure policy is a prime example
  of a Clinical Governance Portfolio.
• Transfusion Practices.
• National Inpatient Medication Chart.

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For More Information

• Contact your local Patient Safety Officer (PSO)
• Log on to the Area Clinical Governance Intranet
  site
• http//intranet.HNE.health.nsw.gov.
• Log on to the NSW Health Quality Intranet site -
• http//internal.health.nsw.gov.au/quality/
• Contact the Area Patient Safety Manager on
  49214927