Voice Patient Safety

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Giving A Voice To Patient

Safet In New South Wales

The Centre for Clinical Governance Research in Health undertakes strategic research, evaluations

and research-based projects of national and international standing with a core interest toinvestigate health sector issues of policy, culture, systems, governance and leadership.

CENTRE FOR CLINICAL

GOVERNANCE RESEARCH



First publishe in 2007 b the Centre for Clinical Governance Research, Universit of New South

Wales, Sne, NSW 2052. Printe an boun b the Universit of New South Wales.

© Jeffre Braithwaite, Joanne Travaglia, Peter Nugus 2007

This book is copright. Apart from an fair ealing for the purposes of private stu, research,

criticism or review as permitte uner the Copright Act, no part ma be reprouce, store

in a retrieval sstem, or transmitte, in an form or b an means, electronic, mechanical,

photocoping, recoring, or otherwise, without prior written permission.

Enquiries ma be mae to Universit of New South Wales.

National Librar of Australia

Cataloguing-in-Publication ata:

Braithwaite, Jeffre

Giving a voice to patient safet in New South Wales

Bibliograph

ISBN: 978 0 7334 2532 5

I. Braithwaite, Jeffre II. Travaglia, Joanne Francis III. Nugus, Peter IV. Universit of New

South Wales. Centre for Clinical Governance Research. V. Giving a voice to patient safetin New South Wales.

dESIGN LAyOUT ANd PRINTING By UNSW PUBLISHING ANd PRINTING SERVICES 39014



Contents

1 Summary 3

2 Introduction 4

2.1 Patientsafetyasacorehealthcareproblem 4

2.2 Tacklingpatientsafety 5

2.3 Givingavoicetopatientsafety 6

3 Methods 7

3.1 Sampleandprocedure 7

3.2 Participants’characteristics 8

3.1 Focusgroupmethodandcontent 11

3.2 Analysisoffocusgroupdata 11

4 Findings 12

4.1 Intermsofpatientsafety,whatkeepsyouawakeatnight? 12

4.2 Haveyourconcernsaboutpatientsafetychangedinrecentyears? 15

4.3 Doyouthinktherearepeopleorgroupswhoareathigherrisk(thanothers)

inthehealthsystem? 184.4 Canyoutellmeaboutthelastincidentthatyouobservedorheardaboutthat

causedharmtoapatientorprolongedtheircare? 20

4.5 Whatarewedoingwellinrelationtopatientsafety? 24

4.6 Whatkeyfactorspreventimprovementstopatientsafety? 30

4.7 Ifyoucoulddoonethingtoimprovepatientsafety,whatwoulditbe? 33

4.8 HaveyouheardabouttheInstituteforClinicalExcellence(ICE),nowthe

ClinicalExcellenceCommission(CEC)? 35

4.9 Additionalcomments 38

5 Discussion 40

6 Conclusion 41

7 References 42

8 Appendices 46

8.1 Appendix1:Summaryoffocusgroupquestions 46

8.2 Appendix2:Demographicquestionnaire 47

8.3 Appendix3:Handout1-ratesofadverseevents 48

8.4 Appendix4:Handout2-responsestopatientsafety 50

8.5 Appendix5:Handout3-patientsafetystrategies 51



Giving a voice to patient safety in New South Wales



Summary

This monograph is the nal in a series prepared by the Centre for Clinical Governance Research (CCGR)

at the University of New South Wales (UNSW) for the Clinical Excellence Commission (CEC). In the rst

two monographs, we reviewed the technical literature on patient safety (Hindle, Braithwaite and Iedema,

2005) and examined major Australian and international patient safety inquiries (Hindle, Braithwaite,

Travaglia and Iedema, 2006). The aim of the series is to shed light on what has become one of the most

important questions in health care practice and management: what do we know about patient safety and

what we can do about it?

This is a social scientic as opposed to a scientic study. We did not design a randomised trial or run an

experiment. Instead, we did something more simple, perhaps more telling: we asked people at the coalface

to talk to us about their concerns about patient safety, what they thought was being done well and what we

could do to make things better. It is very important to capture real life experiences and views in this way,

in order to understand what is going on in the health system from the standpoint of the stakeholder groups

themselves.

In this study we gathered the views of nurses, doctors, pharmacists, allied health professionals, academics

and managers in 30 focus groups across NSW. In total 195 people added their voice to the study. Some

participants were recent graduates; most were senior clinicians and executives. Some of the focus

groups came together as a single discipline; the majority was constituted in mixed groups. We explored

their experiences, sought their opinions about the causes of and possible solutions to breakdowns in

patient safety, and asked them what they thought it would take to achieve the goal of reducing errors and

improving safety for all patients. In answering these questions, participants provided valuable insights into

the ways in which signicant cultural change, leading to improved patient safety, might be achieved.

The information presented in this report shows that patient safety is a problem requiring cohesive and

coordinated solutions. Participants were strongly committed to the current direction and strategies for

addressing medical errors and adverse events, and believed that more work can and should be done.

There was a rm belief that patient safety problems occurred not so much as a result of individual error,

but rather as a result of a combination of poor communication, ineffective teamwork, cultural barriers and

inadequate or inappropriate resource management.

Participants had clear views about the role, and more especially the approach, that the CEC should take

within this context. The CEC, they felt, should take a proactive, strategic and consultative approach, andone which is inclusive of all stakeholders - patients, their carers and families, and health professionals.

In addition, participants thought that the central issues for patient safety were communication and workforce

and workload matters. There was strong support for current initiatives to improve the governance of the

health system, and provide responses to patient safety issues.




2 Introduction

2.1 Patientsafetyasacorehealthcareproblem

Sparked by a series of international inquiries and reports into medical errors and adverse events,

patient safety has become one of the dening movements in health care in the late 20th and early

21st centuries (Bleich, 2005). At all levels of health services including the World Health Organisation

(WHO), policy-makers, bureaucrats, managers and clinicians, there is concern about the causes

and rates of harm. Many people are committed to improving patient safety. Despite this commitment,

health systems, services and professionals are struggling to nd ways to reduce the incidence of

critical incidents and adverse events (Leape, Berwick, Bates, 2002; Watcher, 2004). This is proving

to be what is sometimes called a “wicked problem” – one that is resistant to policy efforts, and ishard to address (Rittel and Webber, 1973).

This monograph is the third in a series produced by CCGR for the CEC. In the rst two monographs,

we reviewed the technical literature on patient safety (Hindle, Braithwaite and Iedema, 2005) and

examined major Australian and international patient safety inquiries (Hindle, Braithwaite, Travaglia

and Iedema, 2006). The aim of the series is to shed light on what has become one of the most

important questions in health care practice and management: what do we know about patient safety

and what can we do about it?

In this monograph we examine some of the human dimensions of this issue. In order to understand

and respond to the causes and consequences of adverse events, it is vital for us to document the

experiences and concerns of health professionals who are, along with patients, at the centre of theincidents causing harm and the efforts to prevent them (Wu, 2000). This has become particularly

important since reviews of patient safety over the last ve years have come to the same conclusion:

progress has been made, but it is limited, patchy and slow, and signicant developments in both

research and practice are required (Watcher, 2004; Bleich, 2005; Longo, Hewett, Ge and Schubert,

2005; Leape and Berwick, 2005; Braithwaite, Westbrook, Travaglia, Iedema, Mallock, Long, Nugus,

Forsyth, Jorm and Pawsey, in press; Iedema, Jorm, Long, Braithwaite, Travaglia and Westbrook,

2006).

In addressing this fundamental question of why, after all that we know about the causes and

consequences of patient harm, the rate of progress remains slow, Pauker, Zane and Salem (2005)

invoke the theory of constraints. Most individuals (and systems), they argue, resist change insome form or another. Factors can include difculties in negotiating what to do, politics, lack of

resources, insufcient training or poor implementation. In order to facilitate the desired change, six

key conditions must be met. There must be agreement: rst, that there is a problem; second, on its

duration; third that the proposed resolutions will actually solve or address it; fourth that initiatives

won’t introduce new problems; fth that it is possible to overcome any obstacles that have been

identied; and sixth, stakeholders must agree to implement the change. We add a seventh: that

progress must be evaluated.

The literature reviewed in the rst monograph of this series (Hindle, Braithwaite and Iedema,

2005) leaves no doubt as to the evidence for the scale of the problem. While there remain some

disagreements about the actual number of errors (Macdonald, Weiner and Hui, 2000; Leape,

2000) and the methods used to identify them (Vincent, 2003: Thomas and Petersen, 2003), it is

not feasible to deny that patient safety is a major concern over and above other technical and

procedural challenges to providing good care (Classen and Kilbridge, 2002). Although there is



variation in the incident rate depending on the study, it is generally agreed that some 10% of all

admissions are associated with an adverse event (Thomas, Studdert, Runciman, Webb, Sexton,

Wilson, Gibberd, Harrison and Brennan, 2000; Runciman, Webb, Helps, Thomas, Sexton,

Studdert and Brennan, 2000; Vincent, Neale, and Woloshynowych, 2001; Davis, Lay-Yee, Briant,

Ali, Scott and Schug, 2003; Schioler, Lipczak, Pedersen, Mogensen, Bech, Stockmarr, Svenning

and Frolich, 2001; Baker, Norton, Flintoft, Blais, Brown, Cox, Etchells, Ghali, Hebert, Majumdar,

O’Beirne, Palacios-Deringher, Reid, Sheps and Tamblyn, 2004).

2.2 Tacklingpatientsafety

The direction of the solutions to the problem, and agreement that the proposed solutions will

be more effective and will not introduce additional problems, is more difcult to determine.

As responses to patient safety proliferate it becomes more, rather than less, difcult to gain

consensus about what should be done, when by whom, and why (Braithwaite, Westbrook and

Iedema, 2005).

What has become evident in recent years is that the complexity of the patient safety problem

requires a comprehensive and concerted, longitudinal approach (Braithwaite, Travaglia,

Westbrook, Jorm, Hunter, Carroll, Iedema, Ekambareshwar, 2006). Current research points

to the need for a combination of approaches: organisational, technological, educational, and

cultural (Braithwaite, Westbrook, Travaglia, Iedema, Mallock, Long, Nugus, Forsyth, Jorm and

Pawsey, in press; Iedema, Jorm, Long, Braithwaite, Travaglia and Westbrook, 2006; Institute

of Medicine, 2001; Larson, 2002; Cohen, Kimmel, Benage, Hoang, Burroughs and Roth, 2004;

Amalberti, Aurory, Berwick and Barach, 2005; Institute of Medicine, 2000; Rosenthal and

Sutcliffe, 2002; Watcher, 2004) at four levels: systemic, organisational, team and individual(Ferlie and Shortell, 2001). This is why the CEC and its programs and projects aiming at

improving quality and safety in multiple ways are so important.

The second monograph in this series (Hindle, Braithwaite, Travaglia and Iedema, 2006) provides

some insights into the obstacles involved in the implementation of patient safety programs. The

authors identied common features in health services that had experienced major breaches in

patient safety. These included: decient quality monitoring processes; the dismissal of concerns

raised by health care providers, patients and families over long periods of time prior to major

patient safety incidents; the ignoring and abuse of active critics of systems or services; decient

teamwork; and lack of involvement of patients and families as part of health care teams.

Various initiatives have been proposed to tackle patient safety. These include: system-wide

quality approaches (Institute of Medicine, 2000; Affonso and Doran, 2002; Ketring and White,

2002); non-punitive incident reporting structures (Barach and Small, 2000; Braithwaite, Travaglia,

Westbrook, Hunter, Carroll, Iedema, Ekambareshwar, 2006) which encourage active learning

from errors (Small and Barach, 2002); dedicated monitoring bodies (Institute of Medicine, 2000;

Dimond, 2002); the development of safety and reporting cultures (Stalhandske, Bagian and

Gosbee, 2002; Larson, 2002; Spath, 2001); effective leadership (Braithwaite, Finnegan, Graham,

Degeling, Hindle and Westbrook, 2004; Mycek, 2001; White and Ketring, 2001); teamwork

(Sprenger, 2001: Turnball, 2001; Mohr, Barach, Cravero, Blike, Godfrey, Batalden and Nelson,

2003; Firth-Cozens, 2001); and involving patients in the team (Robinson and Nash, 2000;

Vincent and Coulter, 2002). The CEC’s work [http: www.cec.health.nsw.gov.au/] is intended to

provide a system wide response to embrace these types of initiatives.



6 Giving a voice to patient safety in New South Wales

These initiatives are supported by most expert commentators, and they are seen as

underpinning a belief in health professionals’ commitment to patient safety. Braithwaite et

al. (2005), for example, found in their evaluation of the NSW Safety Improvement Program

(SIP), that some participants had begun to change their work practices, had improved their

incident reporting practices, and felt that they were better able to address patient safety issues

(Braithwaite, Travaglia, Mallock, Iedema, Westbrook, Long, Nugus, Forsyth, Jorm and Pawsey,

2005;Braithwaite, Westbrook, Mallock, Travaglia, Iedema, 2006; Westbrook, Braithwaite,

Travaglia, Long, Jorm, Iedema, in press).

This literature provides signicant insights into the strategies and approaches which are currently

being employed to reduce errors and improve safety. This phase has been referred to as the “end

of the beginning” (Watcher, 2004). The next era of patient safety has been labelled, a little less

prosaically, as the “hard phase”. It is hard, because it will ask “… health professionals to change not

only their traditional ways of thinking and doing but their images of themselves ….” (Schyve, 2006).In other words, it will demand a signicant culture change from all health professionals, and the

active involvement of health care organisations, policy-makers, educators and other stakeholders

(Mccarthy and Blumenthal, 2006).

2.3 Givingavoicetopatientsafety

In this monograph we sought to give a voice to the health professionals who have lived through

the (at times tumultuous) end of the beginning and who are currently faced with transition to the

hard phase. We gathered the views of nurses, doctors, pharmacists, allied health professionals,

academics and managers in 30 focus groups across NSW. In total 195 people added their voice to

the study. Some participants were recent graduates; most were senior clinical staff and executives.Some of the focus groups came together as a single discipline; the majority was constituted in mixed

groups. We explored their experiences, sought their opinions about the causes of, and possible

solutions to, breakdowns in patient safety, and asked them what they thought it would take to

achieve the goal of reducing errors and improving safety for all patients.

In the monograph we report the major ndings and key themes from our study: what were

participants’ biggest concerns, that is, what kept them awake at night? Had their concerns changed

in recent years? Were there any groups that they felt were at higher risk than others in the health

care system? What were participants’ experiences of medical errors? What is the health system

currently doing well and what needs to be improved? What key factors need to be addressed to

continue improvements? If they could do one thing to improve patient safety, what would it be? Whatshould be the major focus of the Clinical Excellence Commission? The participants provided frank

and honest responses to what were, at times, difcult questions. Most importantly they provided

valuable insights into the ways in which signicant cultural change, leading to improved patient

safety, might be achieved.



7

3 Methods

3.1 Sampleandprocedure

Two sets of focus groups were conducted in order to sample views at different points in time.

The rst set, of 25 groups, was carried out in August and December 2004 by the three authors

from CCGR. Participants were recruited through the Area Health Services (AHSs) in NSW.

Contact was made via Patient Safety Ofcers in each AHS, who helped distribute information

(yers and emails) about the study and arrange suitable times and places for the groups. The

groups were conducted in three major cities in NSW (Sydney, Newcastle and Wollongong) and

in a number of locations, including hospitals, community health centres, ofces, and in one case

a University. Participants were drawn from AHSs, a state-wide health service, and two state-wide health advisory groups. A total of 171 individuals participated in the 2004 groups. Over two

years later the second set of ve focus groups was conducted in order to gauge any changes

in concerns and perceptions of health professionals. This work was conducted in March 2007.

Contact was made via Clinical Governance Units in each AHS. Three AHSs and three state-wide

services responded. The AHSs included both metropolitan and rural locations. Participants were

drawn from a variety of hospital, community health and geographic locations in each service. A

total of 24 participants participated in the 2007 study.

In both sets of focus groups participants came from a range of discipline backgrounds,

metropolitan and rural AHSs, and had different levels of seniority and experience. This was

a convenience sample of academic clinicians, allied health workers (including pharmacists,

physiotherapists, occupational therapists and social workers), nurses (both hospital and

community health), doctors, managers, executives, policy-makers and patient safety and quality

ofcers. We actively sought out a sample which would represent the diversity of professions and

experience in the current NSW health workforce. Participants did not receive payment for their

attendance at the focus groups, but where appropriate, morning or afternoon tea was provided.

For reasons of condentiality, individuals are not identied by name, organisation or AHS, in

either transcripts or this monograph. This requirement meets both ethics requirements and

expressed wishes of a number of participants. The studies were approved by UNSW’s Social

and Health Human Research Ethics Advisory Panel.




3.2 Participants’characteristics

A total of 195 participants attended 30 focus groups. Table 1 below provides details of the numbersof participants in each group, their eld of expertise and discipline backgrounds.

Table1:Characteristicsoffocusgroups

Focus

groupno.Fieldofexpertise Disciplines

No.of

participants

1. Academics (health services research) Academics 6

2. Patient Safety and Quality Managers Mixed 9

3. Community Health Nursing Nursing 9

4. Senior Health Executives Mixed

5. Senior Health Executives Mixed

6. Nurse Unit Managers Nursing

7. Nurse Unit Managers Nursing 6

8. Allied Health Allied Health 7

9. Junior Medical Ofcers Medicine

10. Pathology Mixed 6

11. Infection Control Senior Nursing

12. Nursing Staff Senior Nursing 9

13. Nursing Staff Nursing

14. Quality Managers Mixed

15. Pharmacy Pharmacy

16. Pediatric Nursing Nursing

17. Allied Health Allied health 6

18. Pharmacy Pharmacy

19. Medical/Nursing Mixed 9



22. Nursing New Graduate Nurses

23. Nutrition Mixed

24. Senior Nursing Staff Senior Nursing

25. Senior Nursing Staff Nursing 7Totalfrom2004focusgroups 171

26. Allied Health Allied Health

27. Managers Mixed

28. Nursing Nursing

29. Medical Practitioners Medicine

30. Patient Safety Managers Mixed 6

Totalfrom2007focusgroups 24

Total 195

We collected descriptive data on the samples. Table 2A provides a summary of the characteristics

of the 2004 participants who responded to the demographic questionnaire (n = 158) in Appendix 1.

Note that not all respondents answered all questions.



9

Table2A:Demographiccharacteristicsofthe2004questionnairerespondents

Characteristics Participants

Gender (n = 158)Female (n = 126) 79.8%

Male (n = 32) 20.2%

Age (n = 135)

Age range: 22 – 66 years

Average age: 39 years

Median age: 39 years

Country of Birth* (n = 137)

Australia (n = 92) 67.1%

United Kingdom (n = 20) 14.3%

New Zealand (n = 4) 2.9%

South Africa (n = 3) 2.3 %

Bangladesh (n = 2) 1.5%

Czechoslovakia (n = 2) 1.5%

India (n = 2) 1.5%

Ireland (n = 2) 1.5%

Finland (n = 1) 0.7%

Germany (n = 1) 0.7%

Guyana (n = 1) 0.7%

Hong Kong (n = 1) 0.7%

Malaysia (n = 1) 0.7%

Netherlands (n = 1) 0.7%

Poland (n = 1) 0.7%

United States of America (n = 1) 0.7%

Vietnam (n = 1) 0.7%

Yugoslavia (n = 1) 0.7%

Discipline (n = 157)

Academic researcher (n = 6) 3.8%

Allied health (n = 30) 19.1%

Health services management (n = 13) 8.3%

Medical practitioners (n = 18) 11.5%

Nurses (n = 69) 43.9%

Pharmacists (n = 21) 13.4%

Years of experience (n = 139)

Range of experience: 1 – 40 years

Average years of experience: 15.9 years

Median years of experience: 14 years

Mode for years of experience: 20 years




Highest qualication (n = 134)

PhD (n = 4) 3.0%

Fellowships (n = 10) 7.5%

Masters degree (n = 40) 29.9%

Graduate diploma (n = 18) 13.4%

Graduate certicate (n = 2) 1.5%

Undergraduate degree (n = 44) 32.9%

Diploma (n = 5) 3.7%

Certicate (n = 1) 0.7%

Non-degree nursing qualication (n = 9) 6.7%

TAFE certicate (n = 1) 0.7%

Manager (n = 134)Manager (n = 70) 52.2%

Non manager (n = 64) 47.8%

*Namesofcountriesasstatedbyparticipants

Table 2B provides a similar summary of the 2007 participants who responded to the demographic

questionnaire. Again, not all respondents answered all questions.

Table2B:Demographiccharacteristicsofthe2007questionnairerespondents

Characteristics Participants

Gender (n = 24) Female (n = 19) 79.2%Male (n = 5) 20.8%

Age (n = 13)

Age range: 32 - 62

Average age: 47

Median age: 47

Country of Birth*

(n = 13)

Australia (n = 9) 69.2%

United Kingdom (n = 3) 23.1%

Czech Republic (n = 1) 7.7%

Discipline (n = 14)

Allied health (n = 1) 7.1%

Health services management (n = 2) 14.3%

Medical practitioners (n = 3) 21.4%

Nurses (n = 8) 57.2%

Years of experience

(n = 13)

Range of experience: 2 – 35 years

Average years of experience: 21.6 years

Median years of experience: 14 years

Mode for years of experience: 26 years

Highest qualication

(n = 14)

PhD (n = 1) 7.2%

Fellowships (n = 3) 21.4%

Masters degree (n = 5) 35.7%

Undergraduate degree (n = 3) 21.4%

Non-degree nursing qualication (n = 2) 14.3%

Manager (n = 13)Manager (n = 10) 76.9%

Non manager (n = 3) 23.1%

*Namesofcountriesasstatedbyparticipants



Proportionally, health workers in this study were roughly equivalent to the Australian health

services workforce overall. As of 2005, 10.5% of the Australian health workforce were medical

practitioners, 53.6% were nurses, 6.9% were allied health workers and 2.6% were pharmacists

(Australian Institute of Health and Welfare, 2006). There is a small under-representation of

nurses and over-representation of allied health workers in our sample.

3.1 Focusgroupmethodandcontent

Focus group questions (Appendix 1) were developed via reviews of the patient safety literature

and work on international inquiries into patient safety previously undertaken (Hindle, Braithwaite

and Iedema, 2005; Hindle, Braithwaite, Travaglia and Iedema, 2006). The questions were piloted

with a small group of health professionals (nurses, doctors and allied health), minor modications

made, and the results discarded.

Standard focus group techniques were used (Iedema and Braithwaite, 2004; Krueger and Casey,

2000; Morgan and Krueger, 1997; Puchta and Potter, 2004), although in a few of cases, the

small number of participants (eg, in focus groups 11 and 14) resulted in what would be better

described as a mini-focus group or in-depth interview. Researchers introduced themselves,

outlined the purpose and intent of the focus group and circulated ethics forms and the

demographic questionnaire (Appendix 2). Questions were open-ended to allow for wide ranging

discussion and to tease out a broad range of perspectives. Additional material came from short

written questions which were interspersed with the focus group discussion (Appendices 3 to 5).

Completion of the written questions was entirely voluntary, and in some cases participants chose

not to complete written questions, nor to submit their (unidentied) demographic details. This

was in accordance with the ethics requirements.

Groups typically ran from 1 to 2 hours. The groups were facilitated by at least one of three

researchers, with another present in most cases. All researchers have experience in conducting

focus groups.

3.2 Analysisoffocusgroupdata

Discussions were audiotaped and the tapes transcribed. The focus group transcripts were then

analysed using a formal content analysis procedure (Neuendorf, 2002; Miles and Huberman,

1994). Researchers read the transcripts and identied the key concepts and themes in each

transcript using an iterative, grounded theory approach (Glaser and Strauss, 1967). The themes

were hand coded for analysis via NVivo7, a qualitative data analysis package (Bazeley and

Richards, 2000).

Triangulation (Neuman, 2003; Mertens, 2005; see also Braithwaite, Westbrook, Mallock,

Travaglia, Iedema, 2006; Braithwaite, Westbrook, Travaglia, Iedema, Mallock, Long, Nugus,

Forsyth, Jorm, Pawsey, in press; Westbrook, Braithwaite, Travaglia, Long, Jorm, Iedema, in

press) was achieved using two methods. Firstly, the ndings were reviewed by three researchers

with different discipline bases: organisational psychology, medical sociology and health services

research. Secondly, to conrm validity, the ndings were compared against the extensive

reviews of the patient safety literature and international inquiries previously conducted by two of

the researchers. The overall ndings are presented in the next section, organised to reect the

ow and structure of the focus group questions.




4 Findings

In this section, we present focus group responses to eight key questions: What were participants’ biggest

concerns, that is, what kept them awake at night? Had their concerns changed in recent years? Were there

any groups that they felt were at higher risk than others in the health care system? What were participants’

experiences of medical errors? What is the health system currently doing well and what needs to be improved?

What key factors need to be addressed to continue improvements? If they could do one thing to improve

patient safety, what would it be? What should be the major focus of the Clinical Excellence Commission?

4.1 Intermsofpatientsafety,whatkeepsyouawakeatnight?

Yes, when things go wrong. If someone does a fall at home and you’ve actually been out to

see them, you instantly think ‘was it something I missed?’ You immediately take it on and think

‘was there a way I could have prevented it and have I done all I can?’ Even if they haven’t

already fallen, it’s just ‘have I done all that I can, have I covered everything for the client and for

myself?’ So it’s two things – for the client and for myself and the legalities. (Allied Health Focus

Group)

Health care professionals in each of the 2004 focus groups in this study reported some level of

anxiety about patient harm, medical errors or their contributing factors. For some professionals, the

experiences were direct: the anxiety they felt was as a result of an event they had either personally

been involved in, or had witnessed previously, even years before. Most focus groups, however,

concentrated on issues at the systems, organisation or team level.

The most common systems and organisational concerns identied by focus groups (n = 25) were:

time pressures (n = 9); workload (n = 9); expertise or skills of staff (n = 11); number of staff (n = 7);

education/supervision/support (n = 7); quality improvement (n = 3); and potential and preventable

errors (n = 2).

From our perspective, we’re only [a small hospital], so we have a lot of trouble getting our staff

actually trained … we’ve asked to be invited to other hospitals … so that we can learn from

that. We don’t get any information from the other hospitals in [our AHS] at all so that we can’t

go on the recommendations or look at how many near-misses they have and what they actually

do about it…. (Senior Health Executive Focus Group)

The most dominant systems concerns were issues of workload, time pressures, experience and

numbers of staff. Time pressures were seen as increasing as a direct result of reduction in the

number of experienced staff, which in turn, along with changing patient demographics, had resulted

in increased workloads. These factors were perceived as converging to reduce the level of patient

safety.

I think stafng is one of the problems, the fact the nurses are always so pushed, they are

having to look after so many patients. I think if there was more staff it would help. It would also

be good if there were more pharmacists around as well, because they don’t have time to go

through medication lists, nd out what people came in on, and write lists for the patients when

they go home. Communicate with community pharmacists, things like that …. (Medical Focus

Group)



Staff inexperience was seen as problematic in three ways. Firstly there was a need to supervise

and support new staff more closely, an activity which took more experienced staff members away

from their other duties. Secondly, the lack of experience of junior staff was seen as contributing

to time pressures, as more experienced staff “… get through the work twice as fast and they

don’t miss things.” (Nurse Unit Manager). Agency and casual pool (n = 2) staff were seen as

contributing to time pressures because of the constant need to inform them about the hospital

or teams’ particular policies and procedures. Thirdly, in a small number of groups concern was

expressed about the ability or skills of staff to undertake the work required. Both experienced

and less experienced staff described potential and preventative errors as causing high levels of

anxiety, with one respondent still able to describe waking “… out of a sleep in a sweat thinking

‘oh my God’ ….” years after the event.

While quality improvement strategies were seen as a positive step forward, some questions

remained. These included: the need for standardisation and dissemination of quality andsafety approaches and procedures (which was raised by three groups) to stop “… every facility

reinvent[ing] the wheel as far as policy and protocols go…” ; the question of how to increase

participation in quality improvement activities, particularly by doctors; and how to translated

policies and procedures “… down to oor level.”

At the “oor level” focus groups described issues including: communication, documentation and

feedback (n = 8); teamwork or lack thereof (n = 8); medications (n = 6); appropriate discharge

and or referral procedures (n = 6); falls (n = 5); equipment and environmental issues (n = 5);

and infections (n = 2). Communication, documentation and feedback were seen as impeding

patient safety in two competing ways. Lack of adequate communication and feedback was

seen as preventing improvements in quality and services. Conversely, trying to keep up withdocumentation was seen by one group as impeding the time available to spend with patients.

Similarly, effective feedback was seen as a positive contributor to improvements in safety, but

one participant felt that “… there’s a lack of feedback to staff too, so that problems aren’t xed in

a timely fashion.”

Communication was a recurring theme. The need was expressed for multidisciplinary teamwork,

which was particularly raised by nurses and allied health professionals. The most common

concern was the perceived difculty of allied health, nurses and junior staff in having their

opinions considered and respected, in particular by medical staff. Appropriate discharge and

planning procedures was an offshoot of this concern. Here too, participants raised the issue of

patients being discharged before all professionals, but in particular allied health professionals,

were able to provide input into their ongoing care planning.

There is not a good system of communication. It is very much ad hoc sometimes. We

have many patients. One person says one thing and another person says something

else. Doctors will often walk in and suggest sending someone home. The patient is from

the country somewhere, so there is a lack of planning and lack of forethought in the

communication. In addition, how far do you push things? You do get to the point after so

many years, of being tired of it all – the ethical side of it and the legal side of things. You

sometimes feel that you are not doing as much as you can, but you know that the doctor

does not want to do that sort of thing, so you back off …. (Mixed Focus Group)

Medications were seen as a serious concern, both in relation to the prevention of errors and alsobecause of the potential hazards of multiple medications on factors such as falls. Of the range of

potential medical errors, it was medication errors and falls that were most often raised as specic

examples of patient safety concerns. A pharmacist said this:




It’s usually something I think I might not have done. That drug interaction because patients

have lots and lots of medication and sometimes you’re a bit too busy or too pushed to think of

everything and you think ‘gosh, I must check that tomorrow’ or sometimes you actually forget

to dispense something. You write it on the medication chart that you’re going to dispense

something and have it sent to the ward but you get distracted by someone asking you a

question or you’re talking to the patient and you forget to write it down on your transcription

sheet, so then it doesn’t get dispensed. So sometimes I wake up at night and think about that,

but not very often…. (Allied Health Focus Group)

There were other issues affecting individuals. In terms of staff, there were worries about

accountability (n = 4) and litigation (n = 2). In relation to patients, there were concerns about

patients’: ability to be discharged (n = 5); the acuity of their conditions (n = 4); and open disclosure

(n = 1).

The emphasis is so much on getting the beds free that I nd a lot of people that are in much

longer than they should be, but there’s the other end with people who get discharged who are

medically okay, but they’re not necessarily safe. I had one last night, I was up with her and she

was in theatre … in her late 70s with a fractured wrist and she was discharged at nine o’clock

last night. She’d just got out of recovery at 4 o’clock yesterday afternoon. That is something

that happens a lot …. (Nursing Focus Group)

All participants who raised the issue of accountability spoke to its importance, in particular in

the light of the push for a no-blame approach. Accountability was seen to be needed both at an

individual and at a systems level. Litigation was raised as a concern in two groups. Nosocomial

infections were raised as problems by two groups.

Patients were the central focus of most groups’ responses to the question of what keeps them up

at night. However, most of the discussions were in relation to how organisational issues may affect

patient care and safety. Some additional matters were raised which highlight the role staff play in

actively advocating for patient safety, particularly patients with high needs.

It is important to note that although our line of questioning asked participants about their concerns,

people in three groups said that nothing kept them awake at night, that is, they felt that patients

were relatively safe in their organisation. An Allied Health Professional also offered the following

unprompted insight:

Having said that, things have denitely improved over the last ve years, even the fact that

we are sitting here talking to you. We might not have been asked before. Even though these

are real issues … the fact that we have a system [where] we can report through and with, to

address some of these issues and that we do have a policy in place now … there are positives.

(Allied Health Focus Group)

The 2007 focus groups identied a very similar range of issues. The most common systems and

organisational concerns identied by focus groups were: workload (n = 6); expertise or skills of staff

(n = 5) especially junior staff; ability to provide timely and appropriate care (n = 3) e.g. “not having

enough time to provide what I feel is safe and effective care” ; potential and preventable errors (n

= 3); competing state and organisational priorities and policies (n = 3); overall systems design and

provision (n = 2); access block (n = 1) and the ability to sustain patient safety strategies (n = 1).

Resources continue to remain an issue (n = 2).



There are so many competing things in terms of overseeing and management, for the

whole organisation, that its really hard sometimes to really push the patient safety issue,

sometimes you get drowned out by budgets and other things like that … you are concerned

that some things are not going to get done that could potentially lead to signicant harm

in the future … it is improving and heading the right way, but it seems as though that

the resources don’t allow us to get to the really risky things right away. (Patient Safety

Managers’ Focus Group)

The impact of root cause analyses (RCAs) (n = 2) and the Incident Information Management

System (IIMS) (n = 2) were seen as a double edged sword. On one hand they assisted in the

identication of large numbers of errors and near misses. While this was seen as a positive

development overall, some participants said that given the workforce and resource issued

identied earlier, services were not able to address or prevent a signicant percentage of the

errors identied.

We identify issues on RCAs, we get support and endorsement of executive level to act on

those things and many of them we nd very hard to implement in the workplace, in terms

of time and resources, and then we get another incident when the same issue comes up…

(Management Focus Group).

At a service or ward level, focus groups were concerned about: communication and feedback,

including feedback from RCAs and other safety strategies (n = 7) and handover (n = 2); follow

up and follow through of patients (n = 2) including concerns caused by pressure to discharge

patients (n = 2). Specic error types that were identied by groups included medication errors (n

= 4) and falls (n = 2).

What keeps me awake at night is the void that you feel when you discharge patients …

are they going to receive the timely and appropriate follow up care that you would like? Is

it going to be sustained for long enough? Are they going to get the packages that you have

set up for them? (Allied Health Focus Group)

Staff turnover was considered a signicant issue by one group, as were pressures on senior

staff. A common concern for both staff and patients was their overall safety and security,

particularly in the light of increasing violence (n = 2).

Anxieties about patients centred on higher levels of acuity and complexity (n = 5). A number of

new concerns appeared to focus on specic types of patients. These included: socially and or

geographically isolated patients (n = 3); rapidly deteriorating patients (n = 2); and people with

intellectual disabilities (n = 2).

4.2 Haveyourconcernsaboutpatientsafetychangedinrecentyears?

There is much more emphasis on the governance issues …. Everybody is much more

focussed on that - patient safety issues - and making sure that the systems are in place to

support us in reporting RIBS. We have had training on how to do RCAs and all those things

have improved over the last ve years. (Nursing Focus Group)

Overall, the 2004 focus groups indicated that their concerns about patient safety had changed

in recent years, with most of the systems changes seen as positive. Increased focus ongovernance (n = 4) and patient safety (n = 6) in general was seen as a positive move, along

with staff taking greater accountability (n = 3). The gradual acceptance of a no-blame systems




approach (n = 3) and incident reporting, reportable incident briefs (RIBs) and root cause analyses

(RCAs) (n = 3) were also seen as positive changes. It should be noted, however, that three groups

also raised concerns about incident reporting. These related to the use of incident reporting as

a reactive rather than proactive mechanism for patient safety and a perceived lack of feedback

from the process. More pragmatically, two focus groups commented on the improved use of risk

assessment tools.

There are high risk patients … always invariably on day one, they’ve got a needs assessment

right from day one. To get that [in the past] it would normally take days sorting these patients

out. (Medical Focus Group)

Several focus groups felt that safety had not improved signicantly or that the “real” issues had not

been addressed (n = 6). Some focus groups raised increased workloads as a safety concern (n = 4)

along with the loss of senior staff (n = 2) and the lack of staff or adequately trained staff (n = 8), as

affecting safety. These concerns were often coupled with discussions about the increase in higher

acuity patients (n = 7) and shorter hospital stays (n = 2).

There’s going to be issues everywhere but we’re looking at health systems that started as little

systems, then technology and knowledge changed. So those systems had to incorporate the

new systems which provided the new technology but they’re not blending well. So the mergers

of all those systems have got little splinters all through them. Now you’ve got people training

through systems and they’re back-breaking workloads. Every three months I’m training new

residents. They get half an hour with me [to] tell them how to order safely. (Senior Nursing

Focus Group)

In relation to patients, a number of issues have emerged, most notably the rise of the “awarepatient” (n = 7). This was seen to have both positive and negative manifestations. From the positive

perspective, aware “… patients know now what their medications are, they know what they have to

do if there are any problems.” (Allied Health Focus Group). Patients were seen as being:

… a lot more savvy about their own rights now. I think that’s been a very big transition in the

last ten years, all that American focus on their rights and what they can and can’t do. I think that

creates an element of concern in terms of have we done all we can do to limit or lower the risk

of incidents…. (Nursing Focus Group).

Increased patient awareness was linked to the rise in litigation (n = 4) and negative media coverage

(n = 5). Increases in information technology, especially use of the internet, was identied as having

shaped patients’ expectations (n = 2).

I think also it’s the information age, there’s a lot more medical information easily available via

the internet and other sources, so the average consumer is much more aware; they can go

home from the doctor’s ofce and see if the information they’ve been given is correct, or if

something goes wrong with a relative in hospital they can straightaway get the information to

nd out what’s going on, whereas in the past they couldn’t do that. (Senior Health Executive

Focus Group)

There was also a perception that patients and their families had become more demanding

(n = 2). Aggression, from patients and from other staff (n = 2), was seen as a signicant and

troubling change.



17

I think there’s another way that our customer base has changed too, and that is I think that

issues to do with aggression and violence in the workplace are there now in a way they

were not even ve years ago. It can be verbal and it can be physical, and that introduces a

whole new dimension of stress that causes horizontal problems in teams as well. (Senior

Health Executive Focus Group)

Responsibility for patient safety was seen much more than in the past as being the responsibility

of “everyone” (n = 10). Two groups specically mentioned staff responsibility, and three groups

mentioned the need for patient, or patient and family, responsibility.

I think it’s everybody’s job and we all add to the picture. We all have a piece of the puzzle.

For me, a lot of it is around policy development and strategic planning but for the nursing

sister whom I supervise it is assuring that it actually comes off and they report if they think

something has happened, so I think it’s everybody’s job but once again I think you really

need that time to actually sit and discuss where we all put our pieces together and I don’t

think some people can actually start to think that broadly and widely. It’s not a criticism; I

think that’s just where they are at. (Senior Nursing Focus Group)

The responses from the 2007 participants closely mirrored those of the previous focus groups,

with a perception that commitment to improving patient safety had continued to increase in

recent years (n = 5). One participant described it as reaching “critical mass in terms of safety

awareness” (Management Focus Group). Risk assessment and clinical redesign were mentioned

by one group each as an example of signicant improvements in recent years.

Changes in concerns in recent years were attributed to a combination of factors. These

matched those in the previous focus groups, and included: increased patient awareness (n = 2)particularly as a result of the internet (n = 1); increased expectations from patients and families

(n = 1) including issues of litigation (n = 1) and increased complaints (n = 1) – neither of which

were necessarily seen as negative; increased patient acuity and demographic changes (n = 2)

“safety needs are reecting changes in the client population” ; and shorter stays in hospitals of

sicker patients (n = 1).

Stafng and workforce issues (n = 4) including fewer and more junior staff, a general lack of

resources (n = 2) continue to remain a concern. Increasing administrative demands led one

participant to comment “… I could spend one and a half times my working life in front of a computer.”

The more recent focus groups in effect reected on the maturing of safety improvement

strategies. These include a focus on the sustainability and transfer of quality and safety

improvement programs and projects (n = 3) and integration of a wide variety of projects and

priorities (n = 1). Incident reporting (n = 3) and RCAs (n = 2) were seen as contributing to a

positive change. Although participants openly acknowledged that these strategies contributed

to the identication, reporting and assessment of errors, they also raised concerns about: the

system’s capacity to respond to the causes identied; the focus on RCAs to the perceived

exclusion of other modes of analysis; and the lack of engagement of clinicians, particularly senior

clinicians and doctors, in these processes (n = 2):

I think there has been a cultural change, particularly with nursing staff, I think a lot of

this has been driven by nursing staff who generate the [IIMS] reports, whereas I am not

sure the cultural change is there with the medical staff yet … the issue is more in focus… but the problem I have is getting … senior clinicians to serve on RCAs because they

don’t understand what it’s all about – at that level the message hasn’t gotten through yet.

(Medical Focus Group)




4.3 Doyouthinktherearepeopleorgroupswhoareathigherrisk(than

others)inthehealthsystem?

The 2004 focus group participants mentioned specic population group categories as being at

higher risk than others in the health system. Most common were the elderly (n = 17), followed by

people from non English speaking backgrounds (n = 13), people with mental illnesses (n = 10),

young people and children (n = 4), Aboriginal and Torres Straight Islanders (n = 3) and patients with

disabilities (n = 2). Elderly people were seen as being at risk as a result of a combination of frailty,

increased co-morbidity including cognitive impairments and dementia, and organisational difculties

in providing adequate care.

Thinking about the frail aged, we don’t even have the appropriate physical environment for

them a lot of the time. We don’t have dementia-specic accommodation with secure units; we

don’t have the physical environment to deal with [elderly] patients. We need to look at moreoutside the box stuff, padding oors, pressure-sensitive alarms, those sorts of things. (Senior

Nursing Focus Group)

One focus group also identied the issue of attitudes towards elderly people as a cause of higher

risk. As a Senior Executive put it:

I think there is a need for education, refocusing, particularly, there are growing numbers of

elderly people going into the public hospital system and they call them bed blockers which I

think is a dreadful term. It’s no wonder people develop an attitude that we shouldn’t be looking

after them, they shouldn’t be here…. (Senior Health Executive Focus Group)

People from non English speaking backgrounds were identied as being at risk because of lack of ability to communicate, lack of family members and difculties in accessing interpreters and support

workers. These last three issues were also said to apply to Aboriginal and Torres Straight Islanders.

The second most common group acknowledged as being at risk were patients experiencing various

forms of disadvantage. These included: isolated patients and those without family or support

systems (n = 9); patients from lower socio-economic backgrounds (n = 6); patients who live in

locationally disadvantaged areas (n = 3); patients who are illiterate or can’t communicate (n = 3);

patients experiencing domestic violence (n = 2); and the homeless (n = 1).

A patient without an advocate, whether that be a nurse or relative as an advocate, I think

that patient is at risk. My dad was in hospital last year and I wouldn’t leave his bed, I wanted

to double-check everything that went through, everything he received. Anyone without anadvocate I think is at risk. (Senior Nursing Focus Group)

Locational disadvantage was seen as stemming from three factors. Firstly, rural patients had

to either travel or be transported long distances for adequate treatment. Secondly, there was a

perception that services in locationally disadvantaged areas had fewer resources, and that these

were stretched by the complexity of social and health problems in these areas. Thirdly, there was

a sense that areas of high need were conversely, the least likely to attract highly qualied health

professionals they required.

Patients with co-morbidities (n = 3), cognitive impairment (n = 3), those who were malnourished (n

= 2), obese patients (n = 2), patients with dual diagnoses (n = 1), and patients with drug and alcohol

problems (n = 1), were also identied as being at risk. So too were patients who were bedridden

(and at particular risk of pressure sores), those who were post surgery, and those who had been

discharged early (n = 1 in each category).



19

In terms of malnutrition they say that up to 40 percent of adults and 60 percent of the elderly

admitted to hospital are malnourished and they lose weight in hospital and then go home

malnourished. Data in Australia and around the world has shown that, and basically those

patients are at an increased risk of infection, mortality in general, they’re weaker, not able to do

their physio, so there are all those other issues as well. And up until recently there has been no

community [nutritionist] positions, so basically they go home and they’ve got nothing and some

of the oldies get even more malnourished at home. (Allied Health Focus Group)

Staff were identied as being at risk by three focus groups, specically in relation to aggression

(n = 3), burnout (n = 1), shiftwork (n = 1), tiredness (n = 1) and workload (n = 1). Staff who

were mentioned as being at highest risk were casual staff (n = 1) and new graduates (n = 2).

Aggression towards and between staff was identied as a signicant risk factor. A small number

of examples provided included verbal and physical abuse from patients and family members.

Casual staff and trainees were seen as being at particular risk when they lacked adequate

support and supervision from senior staff. They were also seen as being at higher risk of making

an error. Participants in one focus group argued this way:

Being the casual that didn’t want to work on that ward and got put there because they were

so desperate and were out of their depth. I think those people are really tightrope walking a

lot of the time. (Senior Nursing Focus Group)

Amidst the discussion of risk there was also recognition of the way in which health services were

being delivered effectively to many groups. Although this question focussed on the issues of risk

and vulnerability, this is important to note, as one group did:

Yes, there are many needs being met. The Department of Health [statistics] show that there are

millions of patient encounters every year and there is a lot of good care delivered. With patient

safety, one of the problems with it is it tends to focus on the negatives, not the positives. A lot

of people get their complex birth delivered; their cancer treated, whatever, so we shouldn’t lose

sight of that. There is a lot of good care being delivered. (Academic Focus Group)

A similar range of individuals and groups was identied by the 2007 focus groups. Those

identied as being at higher risk included: the elderly (n = 5): people with mental health

difculties (n = 3) with a special mention of youth (n = 2); young children (n = 3); patients with

high acuity (n = 3) and co-morbidities (n = 2); patients with communication difculties (n =

5), including people from non English speaking background (n = 2) and those with general

communication problems (n = 3); people without family supports or advocates (n = 2); homeless

people (n = 2); people in emergency departments (n = 2); people undergoing surgery or in ICUs

(n = 2); and rural patients or patients who had long distances to travel to access care (n = 2).

Aboriginal and Torres Straight Islander patients were identied as a group at particular risk of

errors of omission, that is, errors as a result of delayed or incomplete treatment. As one focus

group member noted:

That’s the crying shame of it all, we’ve got some really excellent Aboriginal Health Workers

that can engage that population and with some pretty simple interventions early on,

particularly in renal and diabetes you can save a whole heap of morbidity and mortality

down the track … its just that one person … the Aboriginal Health Worker that coaxes them

into treatment or prevention … (Medical Focus Group).




As with the previous question, the second round focus groups identied some similar and some new

issues. These latter included: people with intellectual disabilities and communication impairments

(n = 3); rapidly deteriorating patients (n = 2); and patients being physically transferred, including

prisoners (n = 2). Two groups spoke generally of the “socially vulnerable” and patients who were

seen as being “less desirable” (in society) as being at particular risk.

There was less mention of staff as being at risk, although when they were mentioned, aggression and

violence were still the number one concerns (n = 2). Night staff, frontline staff and staff in small rural

hospitals were identied by one group each. Newer graduates, particularly those in their rst year out,

were also identied as being at particular risk, as were staff who were not coping with the rate of change:

There are a certain number of very good staff … [who] and I see as we go through masses

of change which we have to do in a whole range of areas with the restructure, with a clinical

emphasis, clinical structures – whatever, we are all getting reformed and restructured all the

time and we do have some very good staff who just don’t seem to go with the change or have

change burnout … I think that is a risk area. (Management Focus Group)

4.4 Canyoutellmeaboutthelastincidentthatyouobservedorheardabout

thatcausedharmtoapatientorprolongedtheircare?

Focus group participants’ oral examples of adverse events were categorised according to a schema

developed by the researchers from the Leape, Lawthers, Brennan and Johnson (1993) taxonomy of

common errors and the checklist for RCA teams developed by NSW Health and the Institute for Clinical

Excellence (ICE) (NSW Department of Health, 2004). Each example was given one major classication

(although most had a number of contributing factors) and was only coded once for each group

(irrespective of the number of participants who mentioned the same example). More than one example

was possible in each group. The results from the 2004 focus groups are presented in Table 3 below.

Table3:Typesoferrorsdescribedinthe2004focusgroups

Typeoferror Exampleoferrortype

Diagnostic

Error or delay in diagnosis (n = 2)

A gentleman who has about 20 pressure areas because he

wasn’t picked up by his GP ... and now he is like a one and

a half hour visit, and a huge drain on the service because

of something that could have been prevented. (Community


Failure to employ indicated tests No examples of this error type were recorded in the focus groups

Use of outmoded tests or therapyNo examples of this error type were recorded in the focus

groups

Failure to act on results of

monitoring or testing (n = 1)

This fellow, in those three to four weeks deteriorated. If you

looked at his albumin it was down from 25 to 16 – a massive

decrease – yet when the dietician intervened from day one

they were completely ignored, until they got the stage where

I … had to get the doctor to address the case of this person

being malnourished. This person was not going to recover

from pneumonia if they were starving to death…. (Nutrition

Focus Group)




Treatment

Error in the performance of an

operation, procedure or test (n = 9)

The one that really sticks in my mind is … a patient with a

new trachie [tracheotomy] and there was a problem with the

new trachie but it was still functioning. The registrar who was

on decided that he’d change it, and all the nursing staff were

saying ‘no, no, no don’t change it, you won’t get another one

back in’. He couldn’t get one back in, and he couldn’t ventilate

the patient and the patient nearly died. (Nutrition Focus Group)

Error in administering the treatment No examples of this error type were recorded in the focus groups

Error in the dose or method of usinga drug (n = 16)

It’s how it’s handled. The one medication error that I know I

made, I reported it. I made the mistake, as the manager of

the unit I need to be able to explain to my staff and say it canhappen to you, learn from my error and let’s go through this

process, and if I am using myself as an example, fair enough.

(Senior Health Executive Focus Group)

Avoidable delay in treatment or in

responding to an abnormal test (n = 4)

I followed the notes for a few weeks and I saw this woman

deteriorate with an obvious aspiration pneumonia. She was

coughing, coughing, and steadily deteriorating. She did not

die, but that was because the nursing staff refused to follow

[orders]. (Allied Health Focus Group)

Inappropriate (not indicated care) No examples of this error type were recorded in the focus groups

Preventative

Failure to provide prophylactic

treatment (n = 3)

I had one [new mother] who the night the milk came the

midwife said ‘I’ll take the baby out all night’ and the mother

didn’t express breast milk and ended up with pathological

engorgement…. (Nursing Focus Group)

Inadequate monitoring or follow-up

of treatment (n = 2)

It was a patient who had a peg put in. He had it put in as a day

patient and he was on his own at home. He was given nothing to

go home with, no syringe and no analgesia. He went home and

was back in Casualty next day because he had not idea what to

do. He had no information at all. (Medical Focus Group)

Other

Failure of communication * (n = 6)

Something that could have caused a horrible problem was

a foetus and placenta we were sent from Casualty recently

that we were just told to do a histo on the body. The foetus

in question was recognisably human and I stopped and I

thought, ‘hang on, they might want to bury [the body] or have

pictures or something like that’ so [I waited] and the social

worker got back to me and said ‘no, absolutely not, they don’t

want anything done to it, they want [the body] back to bury.’

(Pathology Focus Group)

Equipment failure * (n = 1)

There was a breakdown of the radiology system here because

our [machine] broke down earlier this year and it still hasn’t

been repaired or replaced and every time we have to do a

[specic procedure] it’s very difcult. We have to drive the

specimen to the nearest lab two hours away and back, and

there is a delay.... (Pathology Focus Group)





Work environment/scheduling * (n = 1)

It was a clear case of someone who was thinking ‘I have myown patients. I can’t deal with this’. This poor [patient] was

obviously being ignored and she was so incredibly distressed

and embarrassed. I thought ‘This is a bad day when nurses

stop caring and think ‘I can’t deal with this’ and walk away,

without referring a situation like that to the nurse’s station.

(Nursing Focus Group)

Knowledge, skills and competence

(training) « (n = 3)

She felt that with this cardiac arrest, rstly, that some people

were not taking any notice of the fact that there was an

arrest and secondly, the staff members on the ward ignored

the fact that there were junior staff members surrounding

this bed and struggling with what they had to do. (Senior


Patient factors « (n = 4)

We had a patient who forgot to take their medication and we

found out two weeks later that they hadn’t been taking the

oral chemotherapy agent they were supposed to be taking,

so we notied the consultant and it prolonged their treatment.

(Nursing Focus Group)

Policies, procedures and guidelines

« (n = 2)

A patient came in and was having a massive hematemesis and

bleed. We have an emergency blood supply here 24 hours a

day and the medical staff and the ED staff did not know about

the emergency blood supply – they rang through to our tertiary

facility to get the blood which took another three hours. The

patient’s blood pressure was bottoming out. The patient did

survive but they were lucky. I checked the blood fridge and

the records and there was an adequate supply of blood in

the fridge and no one knew about it and no one asked about

it. Madly, the same incident occurred a week later…. (Senior


Safety mechanisms « (n = 7)

I had a patient came in, she was very old and extremely frail

with end stage renal disease and she had mild dementia. She

came to us with very mild [illness]… and she went to a bed that

was quite higher than she was used to at home and she got

out of bed to go to the toilet and sustained a head injury and

that was enough to set her off and she wasn’t quite her normal

self. The very next night she did exactly the same thing,

and another head injury. The next day she had a subdural

haemorrhage and died [a couple] of days later…. (Medical

Focus Group)

Other systems failure No examples of this error type were recorded in the focus groups

*Commontobothtaxonomies

«FromNSWHealthChecklist

Medication errors appear most frequently as the most recent adverse event observed (n =

16), followed by error in the performance of an operation, procedure or test (n = 9) and safety

mechanisms (n = 7). In the context of this report, the safety mechanisms category was used to code

falls, where no other contributing factor (eg confusion due to medication) was identied.



Examples of medication errors included cases of omission and commission, that is, both where

the wrong medication was given, and where the correct medication was not provided or delayed

or withheld:

… there’s a lot around warfarin management as well, probably a lot of medical errors and

omissions with that sort of thing, the managing of warfarin and complications at home,

taking it themselves. I don’t know how it’s managed in the community…. (Nursing Focus

Group)

As well as providing an i llustration of medication errors, this example also highlights broader

issues of patient safety. These include patient education and the potential for longer term errors

once the patient has been discharged.

A small number (n = 5) of errors was not identied by focus groups in their discussions. This

included failure to employ indicated tests and use of outmoded tests or therapy, errors inadministering treatments, inappropriate care and other systems failures.

The adverse events identied in 2007 highlight a small range of persistent problems. Error in

performance of an operation, procedure or test (including wrong site surgery) was witnessed by

four groups.

ICU patient received dialysis where the machine was not set up properly - so they arrested,

and they wouldn’t have if the machine was right. (Allied Health Focus Group)

Three groups identied communication failures and a further three “other systems failures”

including two which resulted in completed suicides. Two groups each identied error in the dose

or method or using a drug, failure to act on the results of monitoring or testing, and in avoidabledelay in treatment or in responding to abnormal test.

A double of anti-coagulant effectively and they ended up in ICU – and nearly didn’t make it

and that was very serious. (Allied Health Focus Group)

Groups also gave examples of a range of other errors. These included: error or delay in

diagnosis; inappropriate (not indicated) care; failure to provide prophylactic treatment; work

environment/scheduling; knowledge skills and competence; and failure of safety mechanisms.

An elderly patient with dementia was sent to radiology for an x-ray with a wardsman, but

when they got there the wardsman pointed out … to the radiographer that the patient

appeared … very ill. The radiographer sent them to the ward, but by the time they got there,

the patient was dead. (Medical Focus Group)

As in 2004, a small number of errors was not identied by the 2007 focus groups. This included

failure to employ indicated tests and use of outmoded tests or therapy, equipment failure, patient

factors and policies, procedures and guidelines.

Focus group participants were provided with a handout (Appendix 3) asking about their

perceptions of rates of adverse events in their institutions. A range of staff had experienced

adverse events.

We also asked about minor events. In 2004 medication errors represented the largest category

of minor adverse events identied in the questionnaire. Safety mechanisms (including falls with

no major injuries) ranked second. In 2007 medication errors and falls were equal rst.




In 2004, failure of communication appears third. Examples of minor errors in administering

treatments were provided along with one example of inappropriate care. Unlike in the focus groups,

no examples of failure to act on the results of monitoring or testing was provided. Nor was lack of

knowledge, skills or competence, possibly because these categories could potentially be seen as

a major error. In 2007 there were equal examples of wrong procedures, poor clinical management,

infections and failure of safety mechanisms (one incident each).

Participants were asked for examples of major adverse events. A total of 114 responses was

received for this question in 2004. A number of participants (n = 5) mentioned Severity Assessment

Code (SAC) denitions and another (n = 5) listed “death” or “injury”. The kinds of major adverse

events perceived included inadequate monitoring or follow-up of treatment, error in the dose or

method of using a drug and error in the performance of an operation, procedure or test.

The examples of major adverse events provide a different prole to those of minor events and those

discussed in focus groups. More examples were given in the: safety mechanisms category; cases of

inadequate monitoring or follow-up; and errors in clinician performance. Conversely, fewer examples

of medication errors were provided.

In 2007, 13 responses were received. Major events included: patient deaths from a variety of

preventable causes (n = 4) including falls; attempted self harm and suicides (n = 3); errors in

the performance of procedures (n = 4) including wrong site and wrong patients. One participant

identied medication errors and another, staff members being threatened by violence.

The nal survey question asked participants to estimate the occurrence of medical errors in their

facility. In 2004, on average, 66.7% of participants thought medical errors occurred more frequently

than monthly in their institution. Only 21% thought they occurred rarely or not at all. Failure of

communication was the most frequent error identied by participants (81.6% said it occurred on a

daily or weekly basis). This was followed by errors in the administration of drugs (59.8% said on a

daily or weekly basis). Participants thought these errors occurred on a daily or weekly time scale:

other systems errors (57.7%); avoidable delays in treatment or response (56.6%); with 54.2% of

participants identifying errors or delays in diagnosis; and failures to employ indicated tests (53.4%).

On average, only 48.8% of participants in the 2007 focus groups thought that medical errors

occurred more frequently than monthly in their institution (a decrease of 17.9%). Error in the dose

of methods of using a drug was the most frequent error identied by participants (58.3% said it

occurred on a daily or weekly basis). This was followed by errors in communication (41.7% said on

a daily or weekly basis). Errors which were equally thought to occur on a daily or weekly basis by

participants (33.3%) included: failure to employ indicated test; failure to act on results of monitoring

or testing; errors in administering of treatments; and errors in performance of procedures.

4.5 Whatarewedoingwellinrelationtopatientsafety?

We turn to the fth study question. Here we changed the emphasis, and asked what sorts of things

were going well. One response from a 2004 focus group was as follows:

I think we are denitely reporting patient incidents well. We’re denitely reviewing. Not just

severe incidents, but incidents that we think are important for whatever reason. I think we

have a culture of honesty. I know from my interviews with staff that they are very honest, the

information they tell me, I think that’s very healthy. (Nursing Focus Group)



Patient safety was considered to have improved signicantly in recent years as a result of

changes to the system, and improved organisational and professional cultures. Overall, the focus

on patient safety and the shift to a systems approach (n = 7) was acknowledged as a signicant

step forward in safety, as was incident reporting (n = 5) and a move towards a proactive and

preventative approach to safety (n = 3). The conceptual move from a “blame and shame”

through to a no blame or just blame approach was afrmed as a good development by three

groups. Good care overall was cited by one group.

I think it’s good to have something that will be state-wide, so there’ll be more sharing of

information across the board, so the idea is that we’ll be able to catch something that’s only

happening a couple of times a year in each hospital, but as a whole is happening a lot, so it

will be quicker to put things in place to prevent it happening again. (Nursing Focus Group)

Improvements in various forms of communication were mentioned by a number of groups.

Examples included improvements in: gaining consent from patients (n = 2); collaboration

between groups (n = 2); sharing information (n = 1); talking to patients (n = 1); risk assessments

(n = 1); and feedback (n = 1).

The collaboration with the dieticians and the nurses has again come to the forefront. We are

talking about things, like food charts and understanding the signicance of it, rather than

thinking it is another piece of paper that we have to ll out. The dieticians and nurses are

talking to each other and getting the doctors on board. The doctors are listening to what

everybody is saying and doing it, rather than one group dominating it all. There is more

collaboration now…. (Mixed Focus Group)

A number of groups mentioned particular areas where they felt health services were doingespecially well in terms of safety. These included: infection control (n = 2); aged care

rehabilitation and risk assessments (n = 2); education and training on safety issues (n = 2);

improvements in equipment and technology (n = 2); and the employment of Enrolled Nurses (n =

1). The introduction of Patient Safety Ofcers was also seen as a constructive step (n = 1).

Changes to some aspects of professional and organisational culture were also believed to be

promising. A commitment to, and support of multidisciplinarity (n = 6) was considered a very

positive development, as was the willingness to acknowledge, take accountability for, and learn

from, mistakes (n = 5) and openness, including open disclosure (n = 5).

I think the focus on patient safety is great and it’s very topical at the moment … and the

openness, while it’s still not perfect, it is improving. It’s no longer the sacred domain of the

doctors to be just in the M&M … the doors are slowly opening to allow the multi-disciplinary

teams to participate … people want to be learning; they want to talk about the mistakes that

occur and learn from [them] …. (Nursing Focus Group)

The 2007 focus groups identied a range of strategies, activities and approaches which were

contributing to positive improvements in patient safety at a variety of levels. Clinical governance,

safety champions and more effective responses to patient complaints were each identied by

one group.

The Clinical Governance Unit [in this service] has made a huge difference to the working life

of managers and nurses and patients … having a functioning clinical governance unit, it’s

taken an awful lot of pressure away from patients who were making complaints, and who

[had in the past] not been taken seriously … forcing NUMS and other managers to take the

complaints seriously (Nursing Focus Group).




Macro level changes included acceptance of incident reporting (n = 6); the no-blame approach (n

= 4) and open disclosure (n = 2). At a meso level improvements included a range of nominated

programs, such as TASC, access block, patient ow, falls, medication errors, pressure areas, clinical

redesign and clinical quality. These were seen both as effective strategies in and of themselves, and

as part of the general move towards reective practice and learning from errors (n = 4).

In the last ve years we have come a long way with both the reporting of incidents and the way

we handle them, which is extremely important, the no-blame [approach] which has taken place

in the last ve years or so has allowed people to openly discuss when accidents do happen …

it’s led to a lot more learning. (Management Focus Group)

While incident reporting and RCAs (n = 2) were seen as effective overall, several groups

questioned the time and method taken to input incident data, particularly for senior clinical staff (n

= 2). A number of participants also identied problems with sustaining and embedding safety and

quality strategies either once project funding ran out, or through general lack of resources (n = 2).

Unlike the responses in other questions, which identied the difculty in gaining senior clinicians’

involvement, a participant in one group felt that things were improving:

One thing I can see that is changing slowly but positively is the engagement of senior clinicians,

in terms of being a bit more accountable for the patient safety agenda, rather than seeing it is

a something they could discuss behind closed doors in M&Ms [Morbidity and Mortality reviews]

and leave the systems part of it to the organisation as they weren’t particularly interested, we’ve

really pushed them and ensured they are advised of every issue in their overarching stream

and reporting monthly to them on the implementations and recommendations and making sure

they are around the table. (Patient Safety Manager)

Participants were asked to describe briey their organisations’ responses to the last adverse event

they had witnessed. Table 4 presents the responses from the 2004 focus groups.

Table4:Participants’viewsin2004ofthelastadverseeventtheyobserved

Typesofresponsestoadverseevents(n=101)

Systems responses

Reportable Incident Brief submitted (n = 5)

Root Cause Analysis commenced (n = 10)

Incident report submitted (IIMS) (n = 11)

Organisational/team responses

Investigation (n = 6)

Review and development of education (n = 7)

File or documentation review (n = 1)

Risk assessment (n = 2)

Review and development of policies and guidelines (n = 5)

Review of systems (n = 1)

Change of practice (n = 4)

Review and or change to treatment or equipment (n = 7)

Identication and implementation strategy to prevent future re-occurrence (n = 6)



27

Typesofresponsestoadverseevents(n=101)

Referred to Patient Safety or Quality Manager or Unit (n = 4)

Presented to Mortality and Morbidity Review (M&M) (n = 2)

Discussion at clinical review or safety meeting (n = 3)

Feedback to facility or team (n = 2)

Identication of strategy to support staff (n = 2)

Requested support from colleague or related professionals (ambulance, police) (n = 3)

Individual responses

Discussion with involved parties (staff, General Practitioners) (n = 2)

Discussion with involved parties (patients, carers or families) (n = 3)

Positive response from senior management (n = 3)

Negative response from senior management (n = 1)

Other

No support, response or feedback (n = 11)

Participants’ responses to adverse events can be seen as dividing along systems, organisation

and individual lines. At a systems level, the introduction of various forms of error reporting and

analysis is evident in participants’ responses. At an organisational level a range of investigations

and reviews are undertaken. As well as reactive approaches, proactive changes in practice,

treatment, equipment, policies, and education were identied (n = 23). Some 11 participantsmentioned that they had received no support or feedback in relation to past errors.

The 2007 focus groups recorded similar types of responses. The most common responses were:

IIMS report submitted (n = 4); discussion with involved parties - staff (n = 5) and patients and

their families (n = 3); investigations (n = 3); RCAs; review and development of education; review

and development of policies and guidelines; and referral to Patient Safety or Quality Manager

(each n = 2). Other individual responses included: RIB submitted; review of system; change of

practice; review and or change to treatment or equipment; identication and implementation of

strategy to prevent future re-occurrence; and SAC rating given.

Participants were asked to rate their service’s response to the last adverse event (Table 5).

Almost 100 participants responded in 2004. They were provided with three possible measures:

effective, efcient and whether they felt the action was ethical. While most participants felt that

their services’ response to the last adverse event was effective, efcient and ethical, a notable

minority did not.

Table5:Participants’2004ratingofservices’responsetothelastadverseeventencountered

Evaluationofresponsestoadverseevents

The response was: Yes No

Effective (n = 96) 66 (68.8%) 30 (31.2%)

Efcient (n = 98) 62 (63.3%) 36 (36.7%)

Ethical (n = 95) 70 (73.7%) 25 (26.3%)




A total of 12 responses was received in 2007. Of these, 83.3% thought their services’ response was

effective, 83.3% thought they were efcient and 100% though they were ethical.

There were three nal questions in the questionnaire. The rst asked participants to whom they

go in the case of an adverse event (Table 6). People had clear views on to whom they wanted to

go for assistance or as a rst point of contact in case of an adverse event. Participants were then

asked if they felt they had the authority they needed to get action about their concerns. A total

of 119 participants responded. Of these, 97 (81.5%) said that they felt they had the authority to

get the action they needed, while 22 (18.5%) said they felt they did not. The nal question asked

participants to identify the likely cause of the next adverse event in their facility.

Table6:Participants’2004viewsontheirpointofcontactforadverseevents

Whodo/wouldyougotowhenanadverseeventhappens(withinyourfacility/service)?(n=205)

Area manager (n = 1)

Executive Director or Facility Manager (n = 6)

Director of Service (n = 19)

Head of Department, Team Leader or Unit Manager (n = 17)

Patient Safety or Quality or OHS Manager (n = 14)2004

Governance or Quality or Service Improvement Unit (n = 6)

Appropriate internal Committee (e.g. Adverse Drug Effects Committee) (n = 2)

Immediate supervisor or manager (n = 55)

Medical Consultant, Ofcer or Team (n = 19)

NUM or CNC or CNE (n = 23)

Patient representative (internal to organisation) (n = 2)

Colleagues or peers (n = 8)

Friend/someone trustworthy (n = 2)

Staff (n = 5)

Someone outside facility (n = 1)

Complete RIB and or Incident Report (IIMS) (n = 15)

Myself (n = 3)

No-one (n = 1)

Don’t know (n = 1)

Other (n = 5) (include Legal Liability Ofcer, Counsellor, Employee Assistance Program)

In 2004, participants overwhelmingly said that they would go to their immediate supervisor or

manager in the rst instance after encountering an adverse event, or to their Head of Department

or Team Leader (n = 72). Fewer would go directly to their Patient Safety or Quality Manager or Unit

(n = 20), although 15 participants mentioned that in the rst instance they would ll out an incident

form. Overall, of the 205 responses (more than one response was possible for each participant),

70.4% mentioned going directly to management of some kind, while 4.3% mentioned speaking tocolleagues, friends or peers. The same general pattern held in 2007. Participants said they would

go to their own, or to the line manager of the individual involved, rst. Two participants said that they

would make an incident report in IIMS at the same time.



29

Participants suggested a range of likely causes for the next adverse event in their facility. They

are closely mapped to participants’ perceptions of current causes of errors. The 2004 results are

presented in Table 7 below. More than one response was possible for each participant.

Table7:Participants’2004viewsonthepossiblecausesoffutureadverseevents

Potentialcausesoffutureadverseevents(n=181)

Systems

Increasing cost of medical treatment putting pressure on ED (n = 1)

Organisational

Access issues (n = 2)

Workload and staff – patient ratios (n = 13)

Clinical and work environment (n = 3)

Staff shortages (n = 23)

Skill mix (n = 7)

Time (n = 10), including time to identify source of potential errors

Culture of organisation (n = 1)

Education (n = 5)

Resources and equipment (n = 10)

Lack of services (n = 2)

Communication: inadequate systems (n = 3)

Lack of documentation or access to documentation (n = 3)

Lack of communication between managers and professionals (n = 1)

Team and individual staff members

Attitudes, lack of engagement with patients (n = 5)

Staff inexperience (n = 9)

Poor planning, especially discharge planning (n = 5)

Communication breakdowns and gaps, including lack of referrals (n = 22)

Communication: handovers (n = 1)

Communication: written (n = 2)

Lack of communication between professionals and teams (n = 3)

Not following guidelines, or conicting policies (n = 2)

Continuity of care (n = 3)

Staff stress and low morale (n = 5)

Supervision issues (n = 1)

Individual (patient)

Patient characteristics (n = 5) including co-morbidities, isolation

Lack of support once at home (n = 4)

Non-compliant patients (n = 1)

Types of errors




Potentialcausesoffutureadverseevents(n=181)

Medication errors (n = 17)

Falls (n = 8)

Pathology error (n = 1)

Aspiration (n = 1)

Other

No idea (n = 1)

Litigation (n = 1)

Once again, responses can be mapped to broad systems categories. Responses to this question

reect participants’ responses to the question of frequency of errors: across the board, failure of communication (in its various forms) is identied as the number one contributor to errors (19.3%),

followed closely by workforce issues such as stafng shortages (12.7%), skills (3.9%) and

experience (5.0%) of existing staff, and workload (7.2%).

The 2007 responses (n = 18) showed a similar pattern, although medical errors (22.2%) rather

than communication failures (16.7%) was perceived as the likeliest cause of future events. Other

potential causes included: falls; workforce issues (including increased workloads and isolated

workers); failure to react in time or failure to react appropriately; access issues; and aggression.

4.6 Whatkeyfactorspreventimprovementstopatientsafety?

Could I suggest the organisation of work practices – I guess it relates to culture to some extent,

but just the way the processes of care are organised, the way that people are used to doing

it and sometimes they’re following a 100 year-plus method of apprenticeship, learning craft

delivery, and we’re in a completely different healthcare environment than we were 100 years

ago obviously, and yet the practices are essentially the same, instead of concentrating on the

organisation of workow …. (Senior Health Executive Focus Group)

The factors identied by the 2004 focus groups as preventing improvements closely mirror the

participants’ previous concerns about the issue of patient safety. The focus groups identied a range

of issues at systems and organisational level (including nance, stafng, communication, workload,

co-ordination), and team (including communication, supervision) and individual levels.

Systems level issues included the need for patient safety strategies, guidelines and policies to be

introduced with greater attention to communication of their rationale and potential benets (n = 2).

The need to consult people “at the coalface” in the development of new strategies was mentioned

by one group, while another identied the lack of assessment of the effectiveness of existing

strategies as something which prevented their full implementation. Finance and funding issues were

mentioned by several groups (n = 3).

If you went to the coalface and asked the people who are actually providing the care, they can

come up with some brilliant solutions, but they’re rarely asked, and if they don’t speak up and

suggest them then they’re never heard and it might take ten years to come out …. (Nursing

Focus Group)



Co-ordination between services was identied as a problem (n = 3), and both an acute and

community focus group (n = 2) identied the lack of 24 hour support for patients within their

homes as a signicant concern. Difculties in identifying, communicating with and handing

over to General Practitioners (GPs) was noted by the same groups as an issue in the longer

term safety of patients. In this last case, the impact of bulk-billing, the increase in large medical

centres rather than individual practices and the reticence of GPs to do home visits were issues

of note causing particular concern.

At an organisational level the matter of stafng once again ranked highly. Staff numbers were

identied by three groups as an issue, staff mix and level of experience by four groups, with an

additional two mentioning the increasing “casualisation rate” of staff. The implications of this

were seen as “… if we don’t grab hold of the challenges of training people in those situations

to be part of and recognised as part of the teams as they exist, then we’re gone ….” (Senior

Executive Manager). One group identied concerns about the Enrolled Nurse to RegisteredNurse levels, and expressed concern that this would be an increasing problem in the future.

Three groups mentioned their concern about the ability of staff to meet patients’ needs.

It is time consuming so it’s partly a time factor because you’re so busy trying to look after

your patient and then learning these new skills is taking extra time, to get everything

done on your shift. I stayed back until 11 o’clock the other night because I type with just

one nger and it was past 10 o’clock and I had to write my notes. I had to double check

everything. I had to deal with patients, equipment; there was an in-service on, etcetera….

(Senior Nursing Focus Group)

Resourcing for both staff and services was mentioned by ve focus groups. Two groups

mentioned pressure from senior management about roles and workloads as potentially affecting

patient safety. Two groups mentioned the need to provide training with the introduction of new

technologies, and one group specically mentioned the need for staff release to attend training,

and another supervision, in particular for junior staff (n = 2) as an additional concern. Workload

matters were raised by three groups, with one group mentioning in particular increases in

workload after the introduction of new safety systems.

… the junior medical staff … often have excessive expectations put upon them in terms of

their role and responsibilities by consultants … I think that always produced problems and

to change that really requires consultants to change their practices, how frequently they

come in, how frequently they review the patients, how much they let the registrars do on

their own and how much they actually supervise them. (Senior Nursing Focus Group)

Spanning organisational, team and individual levels were issues of communication and culture.

Discharge and care planning was identied at an organisational level (n = 2). Lack of effective

communication between staff was mentioned as a key factor preventing safety improvements

in ve focus groups. One group also mentioned lack of communication during handovers and a

lack of other types of follow-up as a more generalised organisational-clinical problem.

Existing organisational and team cultural decits were identied as a problem by ve groups,

with one group also mentioning difculty with resistance to change. An additional group

mentioned the need for “… better recognition of adverse events happening …” in other words an

increase in the acknowledgement of errors.




I think we need to change the culture of task orientation, to know that there’s more than just

the simple one, two, three things that you have to do for that patient – a more holistic point of

view, that there might be problems with a patient that are identied before something actually

happens. (Senior Executive Focus Group)

At an organisational and facility level, the workplace environment, including the layout of wards,

was also an issue (n = 2). Follow-up of recommendations of RCAs was identied by one group, with

another mentioning the need for greater creativity in seeking solutions to patient safety issues.

At an individual level, fear was identied as an obstacle to patient safety. Three groups mentioned

fear of litigation as affecting both clinician behaviour and patient safety. In one group a participant

offered the following observation “I still think there’s a big problem of litigation hanging over people’s

heads too. I think it has improved a bit in trying not to have the culture of blame so much ....” In two

cases, focus groups mentioned this fear manifested itself in hyper-vigilance:

So I can well understand where some of the junior doctors are coming from with regards to

over-ordering of tests, they are also aware that it’s becoming a more litigious environment and

they feel the more rudderless they are from up top and the less they feel they can ask, the

more they defend themselves with tests …. (Pathology Focus Group)

The 2007 focus groups identied a different range of issues, although within the same broad

categories of organisational, team and clinician concerns. In terms of organisational issues, it was

systems design, the impact of restructuring and amalgamation “the whole amalgamation of health

services on top of trying to drive the patient safety agenda, in a way that amalgamation dismantled

stuff that we already had in place, and we’ve had to go back and start again” (n = 3). The translation

of research into practice was equally seen as a major factor (n = 3) in preventing improvements.

We talk about evidence, and we spend so much money on research, but it never really gets

to practice – the service model, we still have the same old range of service models despite a

wealth of evidence that they need to change. (Management Focus Group).

Resource issues (n = 4), the volume of work (n = 2), and staff competency and skill mix (n = 2)

continue to be a concern, with the lack of administrative and middle management support receiving

special mention (n = 3). So were demands of increasing workloads on staff in general.

Attitudinal issues were also noted. The silo mentality was identied by one group as being a

problem, as were the attitudes of some staff to patient safety initiatives (n = 3) in general. Some

staff were seen as being affected by burn-out from “too many” different initiatives. The lack of engagement of medical practitioners and senior clinicians in general (“it’s so hard to get medical

compliance on these sorts [TASC] of issues” ) was identied by three groups. This was seen as

being the result of a lack of effective consultation with clinicians and indicated a need to develop

safety and quality improvement strategies specically for this group.

I think that this [lack of clinician engagement] is because they see this as people running

around with clip-boards and the data they do see, they are not sure they can trust … what do

you do right at the very front about what you have to do about getting people to do it, why don’t

you talk to them? ... You need someone very senior and clinical to speak to someone very

senior and clinical to justify their practice. (Medical Focus Group)



4.7 Ifyoucoulddoonethingtoimprovepatientsafety,whatwoulditbe?

… the patient has got to be at the forefront of everybody’s mind really, that is not just fromthe safety perspective, but you always think you have someone on the end of what you

are doing ... [and] something that goes hand in hand with that [is] working well above your

minimum professional standards, but also keeping the patient always in mind too …. (Allied

Health Focus Group)

The strategies identied by the 2004 focus groups as potentially improving patient safety closely

mirror the factors identied as preventing patient safety. Participants identied the following

categories of improvements: stafng; practice issues; culture; development; environment; and

systems and organisational issues.

Stafng was identied as a major factor in improvement, with ten groups identifying increased stafng

as their top priority, with two groups specifying increasing the numbers of Registered Nurses (RNs)

and one arguing for a general increase in experienced staff. Two groups asked for more planners,

one for discharge planners and the other for patient case managers. Two groups wanted more time

to spend with patients and another so that staff are “… not feeling so overwhelmed that they can

actually think about what they are doing and why they are doing it.” Workload was mentioned by two

groups, with one allied health participant making the following plea:

I would increase the number of medical staff in terms of junior doctors available because

the way they have been stretched creates some of the issues. They are not able to listen,

they are not able to attend the meeting and they are truly very stretched. I don’t know how

anyone can work under those conditions. (Allied Health Focus Group)

Practice issues can be essentially patient centred and staff centred. Patient centred issues

included a strong call for patient centred care (n = 8). Two groups suggested taking a holistic

approach to patient care, including pre-screening for issues such as nutritional levels, which

could translate into an increased risk of adverse events (such as pressure sores or infections)

later on.

In relation to staff, the creation of cohesive teams was identied by three groups as a key

issue, with one group mentioning in particular the need for teams with a mix of staff experience.

Improving communication between groups was mentioned by one group, with another identifying

the need for improved communication with patients. One group mentioned a need to increase

staff “heedfulness”, or keeping their focus on the job.

Cultural issues were raised by ve groups. Two issues were identied. These were the need

for a culture shift (n = 3) in relation to patient safety, and the need for awareness, reexivity and

responsibility in staff (n = 2).

… the thing I’ve seen most often is just inaccurate things on medical records, it just

happens because people rush, because they are not listening properly, because of poor

communication, all that sort of thing. They’re the sorts of mistakes I’ve seen, and I’ve seen

a lot of them, and all are completely understandable. I’ve seen very few things happen

because people are basically very poor at what they are doing. The things I’ve seen happen

have been due to stress or due to a particular system. But people are so defensive about

– rather than going ‘I was really tired’. So there’s defensiveness about not correcting things

so things get compounded. (Senior Nursing Focus Group).




Development was another strong category of suggestions for improvement. Peer review (n = 1),

education and training (n = 5), mentoring, involvement in RCA teams, compulsory peer reviews and

strategies for the reduction of isolation of staff (particularly, but not only locationally isolated staff)

were all identied.

Environment was seen as a factor for improvement for both patients and staff. For staff, one group

mentioned the need for a communal space, away from patients, within which staff could talk about

issues. For patients, the re-organisation of the ward environment for patients, and especially ageing

patients at risk of falls, was raised as a needed improvement. One group asked for increased

resources to improve the ward environment overall. A nal group mentioned a successful strategy

that had already been implemented, as a model for the types of improvements they wanted to see:

I was working in rehab and their system had everyone in it. They have a tick list that asks

consultants ‘What are your goals? Have they been achieved? What is going on here?’ so they are

all demanding to get [the patient] out the door in a cohesive system, so that would be great, to do

that and have the consultants more involved on the ward level and for us, to be able to address our

issues as well. Then maybe, we can say to the patient ‘… these are your options. It is ultimately

your decision, and you can decide what happens’ …. (Allied Health Focus Group)

One of the largest groups of comments related to systems and organisational solutions. These

ranged from the very broad such as health care taking a proactive rather than a reactive approach

to patient safety and care (n = 2), including following patients through the system (n = 1), through

to the very specic, such as the re-institution of ward rounds led by NUMS, on a daily basis (n = 1).

A national mandatory reporting system was raised by two groups, as well as a patient identication

system (n = 2), dissemination of information and learning from safety initiatives (n = 1) and co-

operation between health care sectors (n = 1). Services in the community and improvements in

patient transport were each raised by one group. The standardisation of care at all levels (including

the institutionalisation of guidelines) was identied by three groups.

The suggested categories of improvements shifted slightly for the 2007 participants. Increased

staff and reduction in workloads continued to be a major issue (n = 5) for all discipline groups, but a

specic mention of middle management and administrative staff by two groups was new. Improved

communication at all levels of the system remained important (n = 3), with an emphasis on improved

consultation and communication at the “coal face” (n = 2). One group suggested that all services and

departments should “work collaboratively like aged care and rehab … with case conferences and family

conferences” . Improved staff competency (n = 2) was considered fundamental. Better use of information

technology was raised by two groups, particularly in relation to medical practitioners:

The IT strategy is nothing really clinical, its about patient administration, nancial

administration, IIMS which is separate … there is a whole world of clinician decision support

that is just not there – it’s not even a branch of what they are doing … we all know it can be

done … some clinically linked thing that a specialist could say this is the pathway for this

condition and we could all be on the same page. (Medical Focus Group)

Improving the skills of clinicians as well as their procedures was identied as an issue by one group.

They saw the root cause not in individual error itself, but in the training and skills levels of some

clinicians:

If you do the wrong patient’s x-ray … as an example … that would be a SAC 1 – but what my concern which is deeper is the number of unnecessary referrals in the rst place, we are talking

about radiation, which are given in an emergency situation … lack of knowledge of junior

clinicians is much more important to look at . (Allied Health Focus Group)



4.8 HaveyouheardabouttheInstituteforClinicalExcellence(ICE),now

theClinicalExcellenceCommission(CEC)?

A nal question related to participants’ views about the Commission. In 2004 there were high

levels of recognition of this organisation.

That’s the key of where the CEC needs to be. It needs to be the driver to facilitate change.

It has to be at that level or it’s never going to change…. (Senior Nursing Focus Group)

Of the 25 focus groups held in 2004, 24 (96%) of participants had heard either of the Institute

for Clinical Excellence (ICE) or the Clinical Excellence Commission (CEC). One group had not

heard of either of these organisations, and six groups had some members who had not heard

of them, but others had. In 2007 there was a similar level of awareness (96%). Participants

who were unaware of the CEC (n = 1) or unsure of what it did (n = 2) attributed their lack of

awareness to the fact that they had either been recently employed, recently arrived in the

country or because they were in rural services.

Focus groups were asked to make suggestions about the way in which the Clinical Excellence

could support and facilitate improvements to patient safety in NSW. In 2004 they made 53

contributions which we allocated to six categories: benchmarking, programs and activities,

culture change, approaches to patient safety, research and concerns. The responses are

presented in Table 8A.

Table8A:Participants’2004viewsonthewayCECcouldsupportandfurther

improvementstopatientsafety

RoleandfunctionofCEC(n=53)

Benchmarking

Develop a standardised quality system (n = 1)

Establish clear quality goals and benchmarks (n = 4)

Review and standardise policies, guidelines and protocols (n = 4)

Accreditation for aged care sector (n = 1)

Identication of risk factors (n = 1)

Establish an integrative framework with professional and organisational bodies (n = 1)

Ensure auditing and evaluation of quality and safety programs (n = 1)

Identify resources, including technology, to improve safety (n = 1)

Review implication of stafng and workload levels for patient safety (n = 3)

Monitor appropriateness and use of IIMS and SAC criteria (n = 1)

Review organisations’ quality and safety infrastructure (staff, systems, guidelines) (n = 1)

Programsandactivities

Long term programs to improve patient safety (n = 1)

Assist in the development of localised responses to patient safety (n = 1)

Support implementation of guidelines (n = 1)

Establish programs to reduce medication errors and falls (n = 1)

Improve quality of documentation in health services (n = 1)




Restructuring medical education (n = 1)

Support use of evidence based materials (including IIMS data) in educational and practiceprograms (n = 2)

Advocate for nance (n = 1)

Review changes to health services for implications for patient safety (e.g. outsourcing of meals) (n = 1)

Sustaining existing safety and quality programs, like collaboratives (n = 1)

Education and training (n =2)

Culturechange

Change clinician behaviour (n = 1)

Boost morale and pride in health service (n = 2)

Approachtopatientsafety

They need to be proactive about patient safety (n = 1)

Create user friendly approaches to change (n = 1)

Consult with and involve clinicians (n =2)

Acknowledge that quality and safety is an issue in community health (n = 1)

Maintain independence (n = 1)

Broad, strategic perspective on patient safety (n = 2)

Experience the system from the patients’ perspective (n = 1)

Review system down to individual clinician level (n = 1)

Research

Identify what is occurring in the clinical eld (n = 1)

Identication of impact of communication issues on patient safety, including handovers (n = 1)

Concerns

Unless culture is addressed, nothing will change (n = 1)

Not sure a government agency can change clinical behaviour (n = 1)

Difcult to establish a new framework during restructuring (n = 1)

Preferred ICE (n = 1)

Tinkering around the edges (n = 1)

Concerned that they are just going to be a watchdog, and they should be much more than that (n = 1)



37

The 2007 participants made 34 suggestions. These are presented in Table 8B.

Table8B:Participants’2007viewsonthewayCECcouldsupportandfurther

improvementstopatientsafety

RoleandfunctionofCEC(n=34)

Benchmarking

Develop a standardised quality system (n = 1)

Review and standardise policies, guidelines and protocols (n = 1)

Identication of risk factors (n = 1)

Ensure auditing and evaluation of quality and safety programs (n = 2)

Programsandactivities

Models and advice on how to put safety and quality into practice (n = 1)

Programs to increase patient participation (n = 1)

Disseminate “frontline” examples of safety activities (n = 1)

Sustaining existing safety and quality programs, like collaboratives (n = 1)

Culturechange

Engage senior clinicians (n = 2)

Approach to patient safety

Consult with and involve clinicians (n =2)

Maintain independence (n = 1)

Broad, strategic perspective on patient safety (n = 3)

Research

Provide a broader range of evidence (n = 1)

Identication of impact of communication issues on patient safety, including handovers (n = 1)

Concerns

CEC’s ability to reach down to clinician level (n = 3)

Confusion over the number of different Australian quality and safety bodies (n = 2)

Competing DOH and CEC priorities and reporting requirements (n = 4)

Lack of effective consultation before implementation of strategies (n = 3)

Lack of “visibility” including provision of updated information on activities and site visits (n = 3)

Participants were provided a handout asking about their knowledge of current ICE/CEC

activities, and their involvement in and evaluation of those activities (Appendix 5). The results of

the 2004 focus groups are presented in Table 9.




Table9:Participants’2004viewsonthepatientsafetystrategiesofCEC

PatientSafetyStrategies

StrategyIhaveheardof

thisstrategy

Ihaveparticipated

inthisstrategy

Ibelievethisstrategyis

effective

Yes No Yes No Yes No N/A

Blood Transfusion

Improvement

Collaborative (BTIC)

(43.9%)

69

(56.1%)

0

(10.9%)

(89.1%)

27

(28.4%)

(3.2%)

65

(68.4%)

Clinical Governance

Development Program

(CGDP)

74

(59.2%)

(40.8%)

(12.1%)

0

(87.9%)

36

(78.3%)

(8.7%)

6

(13.0%)

Patient Flow and SafetyCollaborative (PFSC)

72(58.5%)

(41.5%)

(24.5%)

74(75.5%)

0(38.5%)

(7.7%)

56(53.8%)

Clinical Risk

Management for Rural

GPs (CRMRGP)

0

(25.0%)

90

(75.0%)

(3.4%)

(96.6%)

(52.2%)

(13.0%)

(34.8%)

Safety Improvement

Program (SIP)

78

(63.9%)

(36.1%)

(33.3%)

64

(66.7%)

(42.9%)

(3.1%)

(54.0%)

Towards a Safety

Culture (TASC) Project

46

(37.7%)

76

(62.3%)

16

(17.2%)

77

(82.8%)

26

(27.4%)

(2.1%)

67

(70.5%)

Research Program

into Safety and Quality

(RPSQ)

(4.7%)

(95.3%)

0(11.0%)

(89.0%)

19(19.6%)

(1.0%)

77(79.4%)

Root Cause Analysis

Training (RCAT)

(72.1%)

(27.9%)

37

(35.9%)

66

(64.1%)

57

(54.8%)

7

(6.7%)

0

(38.5%)

Total446

(47.3%)

496

(52.7%)

143

(19.0%)

609

(81.0%)

259

(39.1%)

31

(4.7%)

372

(56.2%)

In 2007 there was increased awareness of all of the CEC’s programs. Of the participants who

responded to each question: 63.6% had heard of BTIC; 61.5% of CGDP; 81.1% of PFSC; 36.4% of

CRMRGP; 75% of SIP; 58.3% of TASC; 54.5% of RPSQ; and 100% had heard of RCA training.

Participation in these strategies had also increased in all cases except the CRMRGP (no participants

from the 2007 focus groups had been involved in this strategy) and TASC, which had fallen to 12.5%.

A total of 66.7% of all participants in 2007 who responded had been involved in BTIC; 40.0% in CGDP;

37.5% in the PFSC; 62.5% in SIP; 42.9% in RPSQ; and 60.0% in RCA training.

Belief in the effectiveness of training had also increased or stayed virtually the same across

the board. Of the participants who responded to each question the following thought that these

strategies were effective: 60.0% - BTIC; 87.5% - CGDP; 80.0% - PFSC; 40.0% - CRMRGP; 100%

- SIP; 71.4% - TASC; 66.7% - RPSQ; and 100% - RCAT.

4.9 Additionalcomments

Time allowing, participants were given the opportunity to add any comments or reections at the

end of each focus group. In 2004 ten focus groups provided 29 additional issues they wished to see

raised. These are presented in Table 10, grouped into four categories: systems, organisations, team,

professional and individual issues. In 2007, the majority of respondents felt that they had addressed

issues in the previous questions.



39

Table10:Additionalcommentsin2004

Additionalcomments(n=29)

Systemsissues

Increased resources in the community (n = 2)

Patient safety collaboratives in smaller hospitals (n = 1)

Patient safety collaboratives outside of acute care (n = 1)

Re-coupling of quality and safety (n = 2)

Increased resources (n = 1)

Co-ordination of national and state-wide approaches to safety (n = 1)

Use of legislation and benchmarking to encourage compliance (n = 1)

Increase number of nurses (n = 1)

Capturing more information (n = 1)

Organisationalissues

Increased education and training for staff (n = 1)

Staff to assist in transition from hospital to community (n = 1)

Improved feedback on patient outcomes (n = 1)

Positive cultural change and systemic approaches linked with accountability and involvement of

medical staff (n = 2)

Improvement rather than punitive approaches (n = 1)

Use of information technology, including bar-coding and electronic records (n = 1)

Checking and review processes in pathology (n = 1)

Encouragement of safety champions (n = 1)

Team/professionalissues

Multidisciplinary teams that include biostatisticians and epidemiologists (n = 1)

Increase accountability (n = 1)

Recognition of managers’ stress (n = 1)

Assumed knowledge by health professionals about other disciplines, especially nutrition (n = 1)

Improvements to infection control (n = 1)

Individualissues

Fear of lack of support for staff post Camden and Campbelltown (n = 2)

Acceptance of responsibility for errors, including from senior medical staff (n = 1)

Fear of media hindering genuine safety improvements (n = 1)

In the 2007 focus groups, participants were asked about the impact of the CEC over the previous

three years. The CEC was seen has having contributed to the improvements in patient safety

particularly through the TASC Project, the BTIC and a range of other strategies and initiatives

including IIMS. A number of groups commented on the difculty of the CEC’s role and position,

especially in its task of leading system wide change.




Three issues were seen as currently limiting the CEC’s signicant potential impact on health

service delivery. The rst was the visibility of the CEC as an entity independent of the DOH, and

distinguished from other quality and safety bodies. The second was the perceived lack of effective

consultation to AHSs and then to the “grass roots” levels of health services (i.e., to clinicians) and

the CEC’s ability to respond to the needs of people at those levels. Third was the need to improve

co-ordination between CEC and DOH requirements and strategies in order to reduce frustration

amongst managers and clinicians about which activities to prioritise. One focus group pointed out

that some of the issues which were perceived as limiting the CEC’s effectiveness were currently

being addressed by the CEC and that signicant improvements had been made in co-ordination and

communication with AHS over the last couple of months. This positive change was attributed to new

staff at the CEC.

Participants in 2007 also provided some additional suggestions about the future activities of the

CEC. These were very similar to those identied in 2004. They included: the careful selection byCEC of key issues or themes for co-ordinated safety improvement efforts (suggestions included

risk analysis, handover, deteriorating patients, clinical report writing); increased public and clinician

prole, including improvements to feedback and communication to all levels of health services;

return to site visits; provision of best practice models and examples of frontline interventions;

provision, co-ordination and direction of safety and quality educational activities; and specic

strategies to engage senior and other clinical staff.

5 Discussion

These results show that the issue of patient safety in NSW has been identied as a challenge requiring

cohesive and coordinated solutions. The dimensions of the problem have been dened by staff drawn from

various levels and disciplines. Central to the responses was the issue of communication: difculties and

breakdowns in communication, in its various forms, more than any other factor, was seen as contributing to

past and present adverse events.

While central to the problem and its solutions, communication was not the only factor. Broad systems issues,

especially the question of workforce shortages, training and skills levels were common concerns, particularly

from managers. Groups from all disciplines raised questions of adequate workloads, and the issue of time:

time for training, time for reection, and time to care adequately for, as well as treat, patients. Restructuring

was also seen as a barrier to continuous improvements. Changes in patient proles, in particular increasing

numbers of seriously ill patients, patients with mental illness, and patients with cognitive and communication

problems were seen as contributing to the need for highly skilled and focused health practitioners.

Progress has been made in addressing patient safety. Developments in incident reporting and error analysis

provides an indication of recent and signicant changes. Many staff think the NSW health system is on the right

track toward improvement, notwithstanding the challenges that lie ahead. The health system and individuals

are responding to patient safety concerns. The willingness of many participants to report errors, discuss their

concerns with management and colleagues, and participate in rapid reviews and responses can be seen as

suggesting that changes are occurring in the safety culture. So too can the fact that the majority of changes

in recent years were seen as positive; the increased focus on governance and safety, was seen as a step

forward, for example. Several groups argued for further increases in levels of accountability and responsibility

of staff. There was support for the shift away from the old “blame and shame” culture.



Commitment to the current direction in addressing medical errors and adverse events, as well as a

belief that there is more work to be done, can be seen in the perspectives adduced in this study. We

can be cautiously optimistic, particularly as the results from the latest focus groups showed a sustained

commitment to safety improvement and a maturation of concerns, including the need to sustain and embed

systems and practice improvements.

However, in a number of responses, some participants raised concerns about the level of support they

do and would receive in the event of a major adverse event. Obstacles or factors which were seen as

inhibiting improvements to patient safety, aside from stafng levels, centre on communication and teams:

communication between the health care system and management and staff; teamwork between staff, in

particular across disciplines; interaction between teams and services, especially with GPs; and integration

of effort between professionals, patients and their carers and families. In recent years the impact of

restructuring and amalgamations, limited resources and the workforce skill mix were seen as slowing if not

impeding safety improvements.

Participants’ experiences with adverse events and errors, while distressing, are increasingly common.

The concern of participants was less about blame than in the past. Accountability remains a signicant

issue, and the need to take a proactive, rather than reactive approach. All groups were able to provide

examples of both minor and major adverse events. They were also able to provide examples of advances

and improvements either currently underway, or which they are hoping to see in the near future. It is in this

context that the role and value of the CEC to the practising health professional becomes apparent.

Participants provided a wide range of suggestions as to the potential role and contribution of the CEC to

their work lives. Four major categories were identied including establishing benchmarks, conducting new

programs and activities, facilitating culture change, and undertaking research. In addition, participants hadsome denite suggestions about the approach the CEC should take: it should be proactive, strategic and

consultative, and inclusive of stakeholders, especially of professionals and patients. CEC, for its part, is

starting to do this, as its Directions Strategy, Annual Reports and other documentation make clear. [www.

cec.health.nsw.gov.au/]

6 Conclusion

The information presented in this report shows that patient safety is more than a set of technical problems;

rather, it is an organisational issue. The health professionals who gave their time and expertise to speak

in the focus groups made one point very clearly: the issue of patient safety had affected them all. Their

candour in speaking about the issues of medical errors and adverse events, the way in which they were

willing to discuss events that had happened to them or those close to them, and the depth at which

they were all, new graduates and senior executives alike, able to speak about the causes and possible

solutions, was testimony to the professionalism with which they engage with this issue.

None of that is, perhaps, surprising. The people we spoke to are health professionals who are dedicated

to preserving and improving people’s lives, and who, by nature of the research sampling process, are also

people who were willing to come forward and speak openly in a group setting about this issue. What was

telling, however, was the depth of their concern, the passion and commitment to tackling patient safety, and

what this passion and commitment meant to them. The message was loud and lucid: the advancement of

patient safety is as important for the majority as the advancement of health. The challenge is not merely

about the need to improve patient safety, but rather, nding ways in complex, changing, increasingly




scrutinised workplaces so that safety is improved to the benet and satisfaction of both patients and health

professionals. There was a rm belief that patient safety problems occurred not so much as a result of

individual error, but rather as a result of a combination of poor communication, ineffective teamwork, cultural

barriers or inadequate or inappropriate resource management. This is not to say that everyone in every group

agreed: in some isolated cases, individuals felt that the concerns about patient safety had been conated

somewhat, particularly by a sensationalist media.

An unanticipated nding of the research was the strength with which staff essentially held that they, as well

as patients, were vulnerable within the health system. Participants’ major concerns about patient safety

reected this dual apprehension. The most common concern was lack of trained, reliable staff, in virtually all

disciplines, and poor coordination of care. Closely tied to this were the issues of resources and the distribution

of resources across the health system. These require concerted improvement over time.

Staff spoke about the way in which changes to the health system had affected them, and their patients, inrecent years. On a negative note were high levels of uncertainty, staff shortages and for some a sense of

exhaustion in trying to keep up with the pace of change in almost all aspects of service delivery – from policy

development through to practice. On a positive note, the increased concern with patient safety as a whole was

seen as highly valuable, and it was encouraging for our participants to see programs, and to observe multiple

initiatives, which they thought were beginning to pay dividends.

7 References

Affonso, D. & Doran, D. (2002) Cultivating discoveries in patient safety research: a framework.

International Nursing Perspectives, 2 (1), 33-47.

Amalberti, R., Auroy, Y., Berwick, D. M. & Barach, P. (2005) Five systems barriers to achieving

ultrasafe health care. Annals of Internal Medicine, 142 (9), 756-764.

Australian Institute of Health and Welfare (2006) Australia’s health 2006. Canberra, Australian

Institute of Health and Welfare.

Baker, G. R., Norton, P. G., Flintoft, V., Blais, R., Brown, A., Cox, J., Etchells, E., Ghali, W. A.,

Hebert, P., Majumdar, S. R., O’Beirne, M., Palacios-Deringher, L., Reid, R. J., Sheps, S. & Tamblyn,

R. (2004) The Canadian Adverse Events Study: the incidence of adverse events among hospital

patients in Canada. Canadian Medical Association Journal, 170(11), 1678-1686.

Barach, P. & Small, S. D. (2000) Reporting and preventing medical mishaps: lessons from non-

medical near miss reporting systems. British Medical Journal, 320(7237), 759-763.

Bazeley, P. & Richards, L. (2000) The NVivo Qualitative Project Book. London, Sage.

Bleich, S. (2005) Medical errors: ve years after the IOM report. Issue Brief: The Commonwealth

Fund . Accessed on 16 November, 2006. Available at: http://www.cmwf.org/publications/publications_

show.htm?doc_id=289844

Braithwaite, J., Finnegan, T., Graham, B., Degeling, P., Hindle, D. & Westbrook, M. (2004) How

important are safety and quality for clinician-managers? Qualitative evidence from triangulated

studies. Clinical Governance: An International Journal, 9(1), 34-41.

Braithwaite, J., Travaglia, J., Mallock, N.A., Iedema, R., Westbrook, M.T., Long, D., Nugus, P., Forsyth,

R., Jorm, C. & Pawsey M. (2005) Evaluation of the Safety Improvement Program in New South Wales:

overview of studies. Sydney, Centre for Clinical Governance Research, University of New South Wales.



Braithwaite, J., Travaglia, J., Westbrook, M. T., Hunter, C., Carroll, K. & Iedema, R. (2006)

Evaluation of the Incident Information Management System in NSW: overview of studies.

Sydney, Centre for Clinical Governance Research, University of New South Wales.

Braithwaite, J., Westbrook, J.I. & Iedema R.(2005) Restructuring as gratication. Journal of the

Royal Society of Medicine, 98(12), 542-544.

Braithwaite, J., Westbrook, M.T., Mallock, N.A., Travaglia, J.F. & Iedema, R. (2006) Experiences

of health professionals who conducted root cause analyses after undergoing a safety

improvement program. Quality and Safety in Health Care, 15(6), 393-399.

Braithwaite J., Westbrook M.T., Travaglia J.F., Iedema R., Mallock N.A., Long D., Nugus P.,

Forsyth R., Jorm C. & Pawsey M. (2007) Are health systems changing in support of patient

safety? A multi-methods evaluation of education, attitudes and practice. International Journal of

Health Care Quality Assurance. In press.

Classen, D. & Kilbridge, P. (2002) The roles and responsibilities of physicians to improve patient

safety within health care delivery systems. Academic Medicine, 77(10), 963-972.

Cohen, M. M., Kimmel, N. L., Benage, K., Hoang, C. C., Burroughs, T. E. & Roth, C. A. (2004)

Implementing a hospitalwide patient safety program for cultural change. Joint Commission

Journal on Quality and Safety, 30(8), 424-431.

Davis, P., Lay-Yee, R., Briant, R., Ali, W., Scott, A. & Schug, S. (2002) Adverse events in New

Zealand public hospitals I: occurrence and impact. New Zealand Medical Journal, 115(1167),

271.

Dimond, B. (2002) National Patient Safety Agency and the reporting of errors. British Journal of Nursing, 11(12), 808-810.

Ferlie, E. B. & Shortell, S. M. (2001) Improving the quality of health care in the United Kingdom

and the United States: a framework for change. The Milbank Quarterly, 79(2), 281 - 315.

Firth-Cozens, J. (2001) Cultures for improving patient safety through learning: the role of

teamwork. Quality and Safety in Health Care, 10(Suppl 2), ii26-31.

Glaser, B. G. & Strauss, A. L. (1967) The discovery of grounded theory: strategies for qualitative

research. Thousand Oaks, Sage.

Hindle, D., Braithwaite, J. & Iedema, R. (2005) Patient safety research: a review of the technical

literature. Sydney, Centre for Clinical Governance Research, University of New South Wales.

Hindle, D., Braithwaite, J., Travaglia, J. & Iedema, R. (2006) Patient safety research: a

comparative analysis of eight Inquiries in six countries. Sydney, Centre for Clinical Governance

Research, University of New South Wales.

Iedema, R. & Braithwaite, J. (2004) Conducting a focus group: advice and a proposed structure

for those facilitating a focus group. Sydney, Centre for Clinical Governance Research, University

of New South Wales.

Iedema, R. & Jorm, C. (2005) Evaluation of the Safety Improvement Program in New

South Wales: study number 7 (b) - report on RCA focus groups. Sydney, Centre for Clinical

Governance Research, University of New South Wales.

Iedema, R., Jorm, C., Long, D., Braithwaite, J., Travaglia, J. & Westbrook M. (2006) Turning

the medical gaze in upon itself: root cause analysis and the investigation of clinical error. Social

Science & Medicine, 62(7), 605-1615




Institute Of Medicine (2000) To err is human: building a safer health system. Washington, DC,

National Academy Press.

Institute Of Medicine (2001) Crossing the quality chasm: a new health system for the 21st century.

Washington, National Academy Press.

Ketring, S. & White, J. (2002) Developing a system-wide approach to patient safety: the rst year.

Joint Commission Journal on Quality and Safety, 28(6), 287-295.

Krueger, R. A. & Casey, M. A. (2000) Focus groups: a practical guide for applied research.

Thousand Oaks, Sage.

Larson, E. B. (2002) Measuring, monitoring and reducing medical harm from a systems perspective:

a Medical Director’s personal reections. Academic Medicine, 77(10), 993-1000.

Larson, L. (2001) Creating the patient safety mindset. Trustee, 54(9), 18-23.

Leape, L. L. (2000) Institute of Medicine medical error gures are not exaggerated. Journal of the

American Medical Association, 284(1), 95-97.

Leape, L. L. & Berwick, D. M. (2005) Five years after ‘To err is human’: what have we learned?

Journal of the American Medical Association, 293(19), 2384-2390.

Leape, L. L., Berwick, D. M. & Bates, D. W. (2002) What practices will most improve safety?

Evidence-based medicine meets patient safety. Journal of the American Medical Association,

288(4), 501-507.

Leape, L. L., Lawthers, A., Brennan, T. & Johnson, W. (1993) Preventing medical injury. Quality

Review Bulletin, 19(5), 144-149.

Longo, D. R., Hewett, J. E., Ge, B. & Schubert, S. (2005) The long road to patient safety: a status

report on patient safety systems. Journal of the American Medical Association, 294(22), 2858-2865.

McCarthy, D. & Blumenthal, D. (2006) Stories from the sharp end: case studies in safety

improvement. The Milbank Quarterly, 84(1), 165-200.

McDonald, C. J., Weiner, M. & Hui, S. L. (2000) Deaths due to medical errors are exaggerated in

Institute of Medicine report. Journal of the American Medical Association, 284(1), 93-95.

Mertens, D. M. (2005) Research and evaluation in education and psychology. Thousand Oaks, Sage.

Miles, M. B. & Huberman, A. M. (1994) Qualitative data analysis. Sage, Thousand Oaks.

Mohr, J., Barach, P., Cravero, J., Blike, G., Godfrey, M., Batalden, P. & Nelson, E. (2003)

Microsystems in health care: part 6. Designing patient safety into the microsystem. Joint

Commission Journal on Quality and Safety, 29(8), 401-408.

Morgan, D. L. & Krueger, R. A. (1997) Focus group kit (vols 1-6). London, Sage.

Mycek, S. (2001) Patient safety: it starts with the board. Trustee, 54(5), 8-12.

Neuendorf, K. (2002) The content analysis guidebook. Thousand Oaks, Sage.

Neuman, W. L. (2003) Social research methods: qualitative and quantitative approaches. Boston,

Allyn and Bacon.

NSW Department of Health (2004) Checklist ip chart for Root Cause Analysis teams (2 nd

Ed). NorthSydney, NSW Health.



Pauker, S. G., Zane, E. M. & Salem, D. N. (2005) Creating a safer health care system: nding

the constraint. Journal of the American Medical Association, 294(22), 2906-2908.

Puchta, C. & Potter, J. (2004) Focus group practice. London, Sage.

Rittel, H.W.J, & Webber, M.M. (1973) Dilemmas in a general theory of planning. Policy Sciences,

4(2),155-169.

Robinson, J. & Nash, D. (2000) Consumers’ role in patient safety. QRC Advisor, 17(2), 1-3.

Rosenthal, M. M. & Sutcliffe, K. M. (2002) Medical error. San Francisco, Jossey-Bass.

Runciman, W. B., Webb, R. K., Helps, S. C., Thomas, E. J., Sexton, E. J., Studdert , D. M. &

Brennan, T. A. (2000) A comparison of iatrogenic injury studies in Australia and the USA. II:

reviewer behaviour and quality of care. International Journal for Quality in Health Care, 12(5),

379-388.

Schioler, T., Lipczak, H., Pedersen, B. L., Mogensen, T. S., Bech, K. B., Stockmarr, A., Svenning,

A. R. & Frolich, A. (2001) Incidence of adverse events in hospitals. A retrospective study of

medical records. Ugeskrift For Laeger, 163(39), 5370-5378.

Schyve, P. M. (2006) Perspective: patient safety - beyond the ‘easy’ phase. Quality Matters.

Accessed on 16 November, 2006. Available at: http://www.cmwf.org/publications/publications_

show.htm?doc_id=367238

Small, S. & Barach, P. (2002) Patient safety and health policy: a history and review.

Haematology-Oncology Clinics of North America, 16(6), 1463-1482.

Spath, P. (2001) It’s time for a revolution in patient safety culture. Hospital Peer Review, 26(6), 85-86.

Sprenger, G. (2001) Sharing responsibility for patient safety. American Journal of Health-System

Pharmacy, 58(11), 988-989.

Stalhandske, E., Bagian, J. & Gosbee, J. (2002) Department of Veterans Affairs’ patient safety

program. American Journal of Infection Control, 30(5), 296-302.

Thomas, E. J. & Petersen, L. A. (2003) Measuring errors and adverse events in health care.

Journal of General Internal Medicine, 18(1), 61-67.

Thomas, E. J., Studdert, D. M., Runciman, W. B., Webb, R. K., Sexton, E. J., Wilson, R. M.,

Gibberd, R. W., Harrison, B. T. & Brennan, T. A. (2000) A comparison of iatrogenic injury

studies in Australia and the USA. I: context, methods, casemix, population, patient and hospital

characteristics. International Journal for Quality in Health Care, 12(5), 371-378.

Turnball, J. (2001) All components of the systems must be aligned. Healthcare Papers, 2(1), 38-43.

Vincent, C. (2003) Understanding and responding to adverse events. New England Journal of

Medicine, 348(11), 1775-1776.

Vincent, C. & Coulter, A. (2002) Patient safety: what about the patient? Quality and Safety in

Health Care, 11(1), 76-80.

Vincent, C., Neale, G. & Woloshynowych, M. (2001) Adverse events in British hospitals:

preliminary retrospective record review. British Medical Journal, 322(7285), 517 - 519.

Watcher, R. M. (2004) The end of the beginning: patient safety ve years after ‘To err is human’.Health Affairs, 25(6), 534-545.




Westbrook, M.T., Braithwaite, J., Travaglia, J.F., Long, D., Jorm, C. & Iedema, R. (2007) Promoting

safety: varied reactions of doctors, nurses and allied health professionals to a safety improvement

program. International Journal of Health Care Quality Assurance, in press.

Westbrook, M. T., Travaglia, J. & Braithwaite, J. (2006) Evaluation of the Incident Information

Management System in New South Wales: study no. 5 – assessment of the satisfaction of IIMS users

with the system. Sydney, Centre for Clinical Governance Research, University of New South Wales.

White, J. & Ketring, S. (2001) True patient safety begins at the top. Leaders at one large health

system rally around safety, avoid blame game. Physician Executive, 27(5), 40-45.

Wu, A. W. (2000) Medical error: the second victim. British Medical Journal, 320(7237), 726-727.

8 Appendices

8.1 Appendix1:Summaryoffocusgroupquestions

Table 11 summarises the key questions asked of the participants in the focus groups. Questions

were slightly modied according to the location of the group, so for example state-wide groups were

asked to consider the issue from that perspective, rather than from an individual facility perspective.

Supplementary and probing questions were also used to expand the discussions where appropriate.

Table11:SummaryofFocusGroupQuestions

Keyfocusgroupquestions

1) In terms of patient safety, what keeps you awake at night?

2) Have your concerns about patient safety changed in recent years? Why?

3) Do you think there are people or groups who are at higher risk in the health system?

4) Can you tell me about the last incident that you observed/heard about that caused harm to a patient

or prolonged their care?

a) Could you please look at Handout 1, and give us an estimate of the numbers of adverse events you

have observed?

5) What are we doing well in relation to patient safety?

a) Could you please look at Handout 2, and tell us about responses to adverse events6) What key factors prevent improvements to patient safety?

7) If you could do one thing to improve patient safety, what would it be?

8) Have you heard about the Institute for Clinical Excellence now the Clinical Excellence Commission

(CEC)? What impact has it had? What do you think it should focus on?

a) Handout 3 has a list of CEC patient safety strategies. Could you please take a moment to answer

the questions on that sheet

9) Is there anything else I should have asked, or you would like to add?



47

8.2 Appendix2:Demographicquestionnaire

The Centre for Clinical Governance Research, University of NSW has been asked by the NSW

Department of Health and the Clinical Excellence Commission to undertake research into the impact of the

Commission’s programs to improve the safety and quality of healthcare. The following data are collected

to provide a basis for comparison for responses between focus groups.

Completionofthisformisentirelyvoluntary.

If you choose to complete this form, the information will be completely condential.

1. Are you (please tick): q Male q Female

2. What is your age: _______ years

3. In which country were you born?

4. If you were born overseas, please indicate the year you arrived in Australia:

1. Are you of Aboriginal or Torres Strait Islander background? q Yes q No

2. What is your profession or occupation?

3. How many years’ experience do you have in this profession/occupation? _______ years

4. What is your job title?

5. What is your current role(s) at work?

6. How long have you been in this role? ________ years ________ months

7. What is your highest qualication?

8. In which year did you complete that qualication? _________ year

9. Are you a manager? q Yes q No

10. If you work for an Area Health Service, please indicate which one:

11. In what type of facility or organisation (e.g. hospital, CHC, Department of Health/Branch etc) do you work?

12. How long have you worked for your current facility/organisation? ________ years _______ months

13. Have you completed NSW Health’s Root Cause Analysis (RCA) Training? q Yes q No

14. Have you been on any RCA teams in your facility? q Yes q No If yes, how many?




8.3 Appendix3:Handout1-ratesofadverseevents

PartA:Ratesofadverseevents

For the purposes of these questions, an ‘adverse event’ is an unplanned, undesirable event that has a

negative consequence.

1. Thinking of patients in your facility over the last year, how many have suffered an adverse event?

2. How many have had Root Cause Analyses conducted on them?

3. Please provide an example of a minor adverse event:

3 a) What percentage of all adverse events that you know about, do you think are minor?

4 Please provide an example of a major adverse event:

4 a) What percentage of all adverse events that you know about do you think are major?



49

Please place only one tick on each line.

5.HowoftendoyouthinkthefollowingmedicalerrorsoccurswithinyourAHS:

Daily Weekly Monthly

Every

couple of

Months

A couple

of times a

year

Once a

year or

less

Never

Errors or delays in diagnosis

Failure to employ indicated tests

Use of outmoded tests or

therapies

Failure to act on results of

monitoring or testing

Failure to provide prophylactic

treatment

Inadequate monitoring or follow-

up of treatment

Errors in the performance of

operations

Errors in the administering of

treatments

Errors in the dose or methods of

using a drug

Avoidable delays in treatments

or responding to abnormal tests

Errors in the performance of

procedures

Inappropriate (not indicated) care

Errors in the performance of tests

Failure of communication

Equipment failures

Other systems failures




8.4 Appendix4:Handout2-responsestopatientsafety

PartB:responsestopatientsafety

6. Could you briey tell us your facility/service’s response to the last adverse event you observed?

7. Do you think this response was (please tick):

Effective q Yes q No

Efcient q Yes q No

Ethical q Yes q No

8. Who do/would you go to when an adverse event happens (within your facility/service)?

9. Do you feel you have the authority to need to get action about your concerns? q Yes q No

10. What do you think is most likely to cause the next adverse event in your facility/service?



8.5 Appendix5:Handout3-patientsafetystrategies

PleaseAnswerEveryQuestion

SafetyStrategyIhaveheardof

thisstrategy

Ihave

participatedin

thisstrategy

Ibelievethis

strategyis

effective

Blood Transfusion Improvement

Collaborative (BTIC)q Yes q No q Yes q No q Yes q No

Clinical Governance Development

Program (CGDP)q Yes q No q Yes q No q Yes q No

Patient Flow and Safety Collaborative(PFSP)

q Yes q No q Yes q No q Yes q No

Clinical Risk Management for Rural

GPs (CRMRGP)q Yes q No q Yes q No q Yes q No

Safety Improvement Program (SIP) q Yes q No q Yes q No q Yes q No

Towards a Safer Culture (TASC) q Yes q No q Yes q No q Yes q No

Research Program Into Safety And

Quality (RPSQ)q Yes q No q Yes q No q Yes q No

Root Cause Analysis Training (RCAT) q Yes q No q Yes q No q Yes q No

Other (specify): q Yes q No q Yes q No q Yes q No

Other (specify): q Yes q No q Yes q No q Yes q No





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