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Oct 2020 - Foresight Newsletter
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OCTOBER 2 0 2 0
I SSUE 2
Clinical Governance Standard
IN THIS ISSUE :
A preliminary risk assessment (PRA) is undertaken within 72 hours of incident notification, to ensure the safety of people and the environment following a serious incident. Appointment of a dedicated family contact (DFC) - a staff member will be assigned as the primary point of contact for the family and maintains regular communication. A serious adverse event review (SAER) is undertaken with separated reports for findings and recommendations. Serious Harm incidents will no longer be limited to use of an Root Cause Analysis (RCA) methodology. Our Chief Executive may also appoint additional experts in the process to help develop recommendations A safety check is undertaken within 72 hours of incident notification. A corporate Harm Score 1 review is undertaken. There can be one report; or separate reports for findings and recommendations. As with clinical incidents, our Chief Executive may appoint additional team members to help develop recommendations. Towards the end of the year, changes to the Health Act and a revised Incident Management Policy will be introduced to strengthen how we manage serious incidents. Key changes to serious incident management For all Clinical Harm Score 1 incidents, UPCOMING CHANGES TO SERIOUS INCIDENT MANAGEMENT For all Corporate Harm Score 1 incidents, For more information contact [email protected] (Patient Safety Manager, NSLHD) or check out the Clinical Excellence Commission (CEC) website. You can also watch this short video produced by the CEC.
Upcoming changes to Serious Incident Management World Patient Safety Day Medication Safety Month World Thrombosis Day End of Life care - eMR Pilot project Project Spotlight - Carers @ the bedside National Carers week ‘Prompt’ Initiative
World Patient Safety Day is a World Health Organisation initiative to draw international attention to patient safety as a global health priority. This year’s theme for is Safe Health Workers, Safe Patients. At NSLHD, we acknowledge the importance of Speaking Up for Safety and have been training all our staff to, not only speak up when they are concerned, but also to listen for messages of concern from colleagues, and to respond to them. These skills demonstrate that our influence, and our reactions, are effective ways to help keep patients and health care workers safer. This year, more than ever, we need to speak up for patient safety and the safety and wellbeing of those dedicated to delivering it. Find out more about the Safety C.O.D.E and the Speaking up for Safety initiative
You tube (Duration: 2m 24s)
OCTOBER 2 0 2 0
I SSUE 2
Medication Safety Standard
MEDICATION SAFETY MONTH
October is Medication Safety Month.
It is estimated that 2 -3 % of hospital admissions are related to medicines. Some groups have even higher rates of hospital admission related to medicines – for example, for those aged 65 years and over, up to 30% of admissions are related to medicines. Harm may occur because the wrong medicine is prescribed, supplied or used, or because the right medicine is dosed or used incorrectly. Up to 50% of medicine- related hospital admissions are potentially avoidable. Medication Safety Month Poster Competition 2020 This year our staff have submitted posters to share their amazing work in improving medication safety for our patients. You can view these posters on the Medication Safety Month Intranet page and vote for your favourite. Voting closes on the 23 of October. Look out for activities at your local facility and ask yourself what do you do for medication safety? WORLD THROMBOSIS DAY
Check out the new look Medication Safety Intranet site for further information and resources on safe medication practice or contact [email protected] (Medication Safety Improvement Facilitator, NSLHD)
World Thrombosis Day (WTD) is an annual, global initiative to reduce death and disability from thrombosis. Through education and advocacy, WTD seeks to raise awareness of the causes, risk factors, signs/symptoms and evidence-based prevention and treatment of thrombosis among the public and health professionals alike. WTD takes place every year on 13 October, the birthday of Rudolf Virchow who was a pioneer in the pathophysiology of thrombosis.
NSLHD (along with 2,500 organisations and individuals) have partnered with the International Society on Thrombosis and Haemostasis (ISTH) to support this campaign.
Further information, including resources and clinician roles in VTE prevention can be found on the new look VTE Prevention Intranet page Visit our World Thrombosis Day Intranet page to learn about the relationship between COVID-19 and Thrombosis For further information contact [email protected] (Clinical Reliability Improvement Facilitator) or [email protected] (Medication Safety Improvement Facilitator) Know Thrombosis and VTE Prevention This year clinicians from across NSLHD have offered their support and champion the prevention of hospital acquired Venous Thromboembolism (VTE).
OCTOBER 2 0 2 0
I SSUE 1
Partnering with Consumers Standard
Comprehensive Care Standard
Project Spotlight
CARERS @ THE BEDSIDE
The NLSHD Carers @ the Bedside program supports best practice in partnering with patients and their carers to enable patient centered, safe and quality care planning. The Carers @ the Bedside program was launched as an innovation project in 2018 and embedded across wards at Royal North Shore and Ryde hospitals, with implementation currently in progress at Hornsby Ku-ring-gai. The program provides resources for carers to stay overnight at the bedside. These include the provision of recliner chairs, meals, and health education resources for carers and staff. A survey post-implementation of the program found 85% of carers felt the program “always” made them feel included in the decision making around the care of the patient. Clinicians surveyed fed back that having carers at the bedside has allowed improvements to patient care planning by utilising the carer’s knowledge about their loved ones, particularly when there are complex co-morbidities. A survey found that 97% of staff felt that having the carer at the bedside “always” reduced falls risk. Resources and further information can be found on the Supporting Carers at the Bedside Intranet page
EMR – END OF LIFE CARE PILOT PROJECT
NSLHD was accepted to pilot the End of Life Care (EOLC) eMR solution with the pilot commencing on the 15th September 2020. The eMR EOLC enhancement has been developed in partnership with the Ministry of Health (MOH), LHDs, and pillar organisations. The EOLC solution is a new component of the NSW Health eMR which supports clinicians documenting end of life and palliative care. The eMR End of Life Care functionality will be used by generalist and specialist palliative care clinicians to enable patient-centred palliative care services for inpatient and community settings. Clinicians will document patients' palliative care and end of life needs using electronic palliative care clinical assessment forms, tools and reporting. For example, the eMR EOLC solution will streamline and automate aspects of the Sub and Non Acute Admitted Patient (SNAP) reporting process. Additionally, facilities participating in the Palliative Care Outcomes Collaboration (PCOC) can collect >Page 1 Page 2 Page 3 Page 4
www.nslhd.health.nsw.gov.au
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