An Introduction to Patient Safety

Learning objectives Understand the role of the

Patient Safety Centre Understand the concept of

clinical incidents Be aware of what can cause

harm to patients Know the correct processes for

reporting incidents

Patient Safety Centre

Established in 2005 The purpose of the centre is to

minimise patient harm caused by healthcare

Patients can be harmed physically and/or psychologically due to a variety of factors during the provision of care.

How much harm is there? 16.6% of hospitalisations are

complicated by adverse events 14% of these adverse events result in

the patient with a permanent disability 5% of adverse events result in death 50% of all clinical incidents are

preventable 80% of clinical incidents occur due to

communication failures Estimated financial cost $4.3 billion yr

What factors can harm patients?

Systems failures Human factors Communication breakdown Equipment faults and operation errors Workplace cultures Insufficient procedures Training deficiencies Deficits in understanding the

boundaries or level of clinical service provided

Adverse event An adverse event in health care is a

clinical incident in which unintended or unnecessary harm resulted

Adverse events are not always recognised by staff – sometimes they are put down as “a complication”

The simple question to ask yourself is – ‘has the patient suffered a unexpected outcome of healthcare?’….if yes, it is a clinical incident

A clinical incident Clinical incidents are not a reflection on

an individual, a team or a workplace Incidents will always happen Incidents are usually the outcome of a

chain of events Managing these incidents and, Learning from incidents is the

professional response to incident management

Incident management This document applies to

all Queensland Health staff It describes how to report,

escalate, manage and analyse incidents for learning

It is every-one’s role to report incidents- even near misses

Reporting a clinical incident

Every health organisation will have a system for reporting clinical incidentsAll incidents including near misses need to be reportedFamiliarise yourself with the systems in your organisation

Reporting a clinical incident

Every computer in Queensland Health has a symbol on the desktop- clicking will take you to PRIME-Clinical Incident reporting database

Reporting Concerns.lnk

Reporting a clinical incident- PRIME

PRIME is simply a data base to record your report- and helps to automatically escalate where needed-it does not manage the incident

A password is not needed to report Line managers must manage your

report and escalate if support is needed for the family or specialist analysis is needed

Patient Safety Centre- PRIME

If an incident has resulted in likely permanent harm or death – it is given a category rating of 1. Known as Severity Assessment Code 1 or SAC1

Where the incident has resulted in temporary harm it is given a category rating of SAC 2

Where the incident has resulted in no or minimal harm it is given a category rating of SAC 3

Patient Safety Officers Where SAC1 events occur the District Patient

Safety Officer (PSO) will become involved Their role is to advise District Executive on

managing the incident for the family/ patient involved- using the

open disclosure process with incident analysis processes in

accordance with legislation (root cause analysis)

Patient safety activitiesAnalysis of the 200,000 or more incidents shows special effort is needed incorrect site surgerypressure ulcer preventionfalls programmental healthopen disclosurealerts and recallspatient identification

Patient Safety CentreThe centre also provides and assists training Queensland Health Staff in:Root Cause AnalysisHuman Error and Patient Safety Open disclosurePRIME database managementCoronial managementCheck with your local Patient Safety Officer for further training

You are patient safetyReport clinical incidents early which: ensures Queensland Health response helps affected families and staff helps with system improvement and

minimises further harm or reoccurrence you can contact your district Patient Safety

Officer or find them through at: http://qheps.health.qld.gov.au/patientsafety/http://www.health.qld.gov.au/patientsafety/default.asp

Learning Activity

Please complete the learning

activity