In the latest issue (attached below): 

There will be opportunities to hear about the latest infection prevention and control research along with infection prevention and control challenges in acute, community, residential aged care and office base practice settings.

To find outmore abotu this event, go to:  http://acipcconference.com.au/

The May 2015 edition of Medication Safety Watch is now available online. This bulletin is for health professionals and health care managers working with medicines or patient safety. It contains information about medicine-related incidents, errors and adverse drug reactions and offers recommendations on how to improve medication safety.

This Account focuses on the quality of services Hutt Valley DHB provided during 2013/2014.

Contents include: Health targets; Quality & safety markers; Serious adverse events; Patient experience Receiving care closer to home; Getting in shape before joint surgery; Getting better at home; Helping cancer patients find their way; Encouraging attendance; Community Safety Initiatives HealthPathways; More heart and diabetes checks; Help quit smoking; Disability services; Empowering staff; Giving babies the best possible start; Patient safety initiatives; Open campaign; Care capacity demand management; Electronic whiteboard; Newborn hearing screening; Malnutrition screening & training; Supervisor training; Looking forward; Future Focus.

This Quality Accounts is available to read in full text at:  http://www.huttvalleydhb.org.nz/content/10ff5f6d-fe7e-4a44-8667-5b72672d3214.html

Twenty-one studies were included, with most being before–after interventions. The authors conclude from their analysis that due to methodological and reporting limitations, "... the observed reduction in CDI may not be entirely attributable to interventions. Although infection control programmes involving education and handwashing/gloving protocols were found to have contributed to a reduction in the incidence of CDI, these measures were usually a component of multi-faceted interventions that did not provide for evaluation of the relative impact of each factor. Appropriate environmental disinfection and antibiotic stewardship would appear to offer the most effective benefits".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.jhin.2015.02.015 or contact your DHB library, or organisational or local library for assistance.

Khanafer, N., et al. (2015). Hospital management of Clostridium difficile infection: A review of the literature. The Journal of Hospital Infection, 90(2), 91-101.

In this study, the authors report patients’ views of the various contributory factors to creating safe primary care.

A continuous quality improvement programme with ‘Plan-Do-Study-Act’ cycles was implemented and, to monitor compliance, an electronic tool was designed as part of a bedside clinical information system. Dedicated line insertion trolleys and factory-prepared insertion packs were also introduced. 

The authors conclude from the results of their analysis that "implementation of evidence-based care bundles reinforced by real-time feedback on the performance of caregivers can significantly reduce the rate of catheter-related bloodstream infection in the intensive care unit. Ensuring that change processes are seamlessly integrated in the workflow with minimal administrative burden is crucial to the quality improvement process".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/nicc.12186 or contact your DHB library, or organisational or local library for assistance.

Hermon, A., Pain, T., Beckett, P., Jerrett, H., Llewellyn, N., Lawrence, P. and Szakmany, T. (2015), Improving compliance with central venous catheter care bundles using electronic records. Nursing in Critical Care. 

For this study complaints received from November 2011 through June 2012 and HLI incident reports from April through September 2012 were examined. Complaints and HLIs were categorised according to location or specialty and the themes they included. Data were analysed to look for correlations between number of complaints and HLIs in a given area. A qualitative analysis was carried out to determine whether any complaints contained information that, if acted upon earlier, could have prevented later HLIs.

In the data a total of 52 complaints and 16 HLIs were included. No correlation was established between location of HLIs and complaints. Complaints commonly focused on staff attitude, diagnostic problems and delayed treatment. HLIs most often arose from failure to recognise a patient’s deterioration and escalate appropriately or incorrect patient identification. Most HLIs were not preceded by similar complaints. However, in two instances complaints did signpost future HLIs.

The authors conclude that patient complaints can highlight specific risks to patient safety and act as an early warning system. There is a need to devise reliable means of identifying the minority of complaints that do precede serious incidents.

This is an open access article and can be downloaded and read in free full text at: http://pxjournal.org/journal/vol2/iss1/14

Kroening, Helen L.; Kerr, Bronwyn; Bruce, James; and Yardley, Iain (2015) Patient complaints as predictors of patient safety incidents. Patient Experience Journal, 2(1), 14.

To find out more on the HQSC website, go to:  http://www.open.hqsc.govt.nz/news-and-events-2/news/2148/

Searches identified 46 calculators that performed simple mathematical operations using planned carbohydrate intake and measured blood glucose. While 59% of apps included a clinical disclaimer, only 30% documented the calculation formula. 91% lacked numeric input validation, 59% allowed calculation when one or more values were missing, 48% used ambiguous terminology, 9% did not use adequate numeric precision and 4% did not store parameters faithfully. 67% of apps carried a risk of inappropriate output dose recommendation that either violated basic clinical assumptions (48%) or did not match a stated formula (14%) or correctly update in response to changing user inputs (37%). Only one app, for iOS, was issue-free according to our criteria. No significant differences were observed in issue prevalence by payment model or platform.

The authors conclude that the majority of insulin dose calculator apps provide no protection against, and may actively contribute to, incorrect or inappropriate dose recommendations that put current users at risk of both catastrophic overdose and more subtle harms resulting from suboptimal glucose control. Healthcare professionals should exercise substantial caution in recommending unregulated dose calculators to patients and address app safety as part of self-management education. The prevalence of errors attributable to incorrect interpretation of medical principles underlines the importance of clinical input during app design. Systemic issues affecting the safety and suitability of higher-risk apps may require coordinated surveillance and action at national and international levels involving regulators, health agencies and app stores.

This is an open access article and is available to read in free full text at:  http://dx.doi.org/10.1186/s12916-015-0314-7

Huckvale, K., et al. (2015). Smartphone apps for calculating insulin dose: A systematic assessment. BMC Medicine, 13:106.

"Three crosscutting priority areas were identified: medication management, assessment and referral, and treatment. The 4 incident types associated with the most harmful outcomes are errors associated with diagnosis and assessment, delivery of treatment and procedures, referrals, and medication provision. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death".

The authors discuss the implications of these findings.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1542/peds.2014-3259 or contact your DHB library, or organisational or local library for assistance.

Rees, P., et al. (2015). Safety incidents in the primary care office setting. Pediatrics, 135(6).

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1186/s12916-015-0335-2

Yealy, D.M., et al. (2015). Recognizing and managing sepsis: what needs to be done? BMC Medicine, 13:98.

Contents include:

• The home hemodialysis hub: Physical infrastructure and integrated governance structure 
• Funding and planning: What you need to know for starting or expanding a home hemodialysis program 
• Workforce development and models of care in home hemodialysis 
• Systems to cultivate suitable patients for home dialysis 
• Patient safety in home hemodialysis: Quality assurance and serious adverse events in the home setting 
• Patient selection and training for home hemodialysis
• The care and keeping of vascular access for home hemodialysis patients 
• Home hemodialysis: Infrastructure, water, and machines in the home 
• Prescriptions for home hemodialysis
• Psychosocial aspects in home hemodialysis: A review

The manual is available to read in free full text at: http://dx.doi.org/10.1111/hdi.12314

The April 2015 edition of Let's Talk Triggers is now available on the Health Quality & Safety Commission's website. This quarterly newsletter from the Commission's Global Trigger Tools programme contains updates, trigger tool tips, featured articles and other items on patient safety. 

The successful implementation of the Midland Region ePharmacy system was achieved at Lakes District Health Board, Rotorua and Taupo hospitals at the end of March. 

Lakes DHB is the first DHB in the Midland DHB region to go-live, with the Lakes DHB pharmacy team having been at the forefront of testing and implementation of the new pharmacy programme. Epharmacy is the first clinical system to be developed for a regional shared solution. The ePharmacy initiative allows all aspects of hospital pharmacy practice to be managed within a single system, allowing Lakes DHB to track pharmacy dispensing, inventory and cost centre accounting requirements. 

The new ePharmacy system has replaced an earlier electronic system, the Galen pharmacy dispensing and stock management systems at Rotorua and Taupo hospital pharmacies. 

There are a range of benefits expected from the ePharmacy implementation at Lakes and the other Midland DHBs, Taranaki, Tairawhiti, Bay of Plenty and Waikato DHBs, in the medium and longer term, once further changes around the Safe Medication Management programme is further along the track. 

Medication errors are one of the single most common causes of unintended harm to patients. MedChart will provide Lakes DHB (and the other Midland DHBs) with an end-to-end electronic medication management (eMM) solution, helping healthcare organisations reduce clinical risk and improve medication safety. MedChart eliminates complex, time-consuming manual and paper-driven medication management processes, reducing errors, improving efficiency and enabling greater coordination between clinical teams for better patient care. 

MedChart is tried, tested and proven, used by leading hospitals in Australia, New Zealand and the UK, and includes a range of separate workflows for optimum medication management. 

The General Manager Clinical Services for Lakes DHB, Dale Oliff says the Lakes go-live comes after lengthy planning and hard work by a range of staff , with the regional decision to proceed made some five years ago. 

The second Midland DHB to implement ePharmacy was Tairawhiti DHB in mid-April. Waikato, Bay of Plenty and Taranaki DHBs will go-live over May and June. 

The latest issue of the Health Quality & Safety Commission's e-update for the period 30 March to 19 April 2015 is now available online. This issue includes:

In this issue:

• Collaboration leads to impressive achievements
• DHB performance against the SSII Programme’s clinical practice recommendations
• DHB improvement profiles.

To download and read the update, go to:  http://www.hqsc.govt.nz/our-programmes/infection-prevention-and-control/publications-and-resources/publication/2115/

Practitioners frequently encounter safety problems that they themselves can resolve on the spot. In this qualitative study, the authors ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? They consider factors underlying these two approaches.

From 2002 to 2010, 351 170 803 patients were admitted to U.S. hospitals, with 19% admitted on a weekend. Hospital acquired conditions occurred at an overall frequency of 4.1% (5.7% among weekend admissions versus 3.7% among weekday admissions). Adjusting for patient and hospital cofactors the probability of having one or more hospital acquired conditions was more than 20% higher in weekend admissions compared with weekday admissions (odds ratio 1.25, 95% confidence interval 1.24 to 1.26, P<0.01). Hospital acquired conditions have a negative impact on both hospital charges and length of stay. At least one hospital acquired condition was associated with an 83% (1.83, 1.77 to 1.90, P<0.01) likelihood of increased charges and 38% likelihood of prolonged length of stay (1.38, 1.36 to 1.41, P<0.01).

The authors conclude that weekend admission to hospital is associated with an increased likelihood of hospital acquired condition, cost, and length of stay. They go on to say that future protocols and staffing regulations must be tailored to the requirements of this high risk subgroup.

This is an open access article and is available to read in free full text at:  http://dx.doi.org/10.1136/bmj.h1460

Attenello, F.J., et al. (2015). Incidence of “never events” among weekend admissions versus weekday admissions to US hospitals: National analysis. BMJ, 350:h1460.

The objective of this Australian study was to investigate long-term trends in injury profiles of elderly patients who have fallen, and to identify injuries associated with need for in-patient rehabilitation. Analysis over the past decade found a significant decrease in hip fractures from low-energy falls but this was associated with a rise in severe head injuries. Around 25% of patients were transferred to in-patient rehabilitation.

Now available to read in free full text at: http://onlinelibrary.wiley.com/doi/10.1111/ans.12676/abstract 

Lee, H., et al. (2015). Changing patterns of injury associated with low-energy falls in the elderly: A 10-year analysis at an Australian Major Trauma Centre. ANZ Journal of Surgery, 85(4), 230–234.

http://www.open.hqsc.govt.nz/medication/publications-and-resources/publication/2041/

Over a 10-month period, they developed processes to report harm, and used the Model for Improvement and multiple Plan, Do, Study, Act cycles for testing. They measured changes using culture surveys as well as analysis of the reports. The tool was tested in different formats and moved from a provider centric to a person-centred tool analysed in real time. An independent person working with the families was best placed to support reporting.

Immediate feedback to families was managed by senior staff, and provided the opportunity for clarification, transparency and apologies. Feedback to staff provided learning opportunities.

Improvements in culture climate and staff reporting were noted in the short term. The integration of patient involvement in safety monitoring systems is essential to achieve safety. The high number of newly identified ‘near-misses’ and ‘critical incidents’ by families demonstrated an underestimation of potentially harmful events. This testing and introduction of a self-reporting, real-time bedside tool has led to active engagement with families and patients and raised situation awareness. The authors believe that this will lead to improved and safer care in the longer term.

This is an open access report and can be read in free full text at:  http://qualitysafety.bmj.com/content/early/2015/03/30/bmjqs-2014-003795.full

Lachman, P., et al. (2015). Developing person-centred analysis of harm in a paediatric hospital: A quality improvement report. BMJ Quality & Safety, 24:337-344

Health Minister Jonathan Coleman says cases where a woman becomes seriously unwell during maternity care will now be audited by a panel of experts.

“It is important that new mothers and babies receive high quality care across New Zealand,” says Dr Coleman.

“Safer maternity services are a priority for this Government – that's why in Budget 2012 we invested an extra $103 million over four years into improving maternity services.”

The Severe Acute Maternal Morbidity Audit looks into cases where pregnant or recently delivered women had been admitted to ICU and looks for factors that may have been avoidable.

The reviews are carried out by a multi-disciplinary panel of experts, including obstetricians, midwives, anaesthetists, and intensive care specialists.

Following a successful feasibility study involving four DHBs, the national audit process has been trialled for the last two years in all DHBs.

To date over 300 anonymised cases have been reviewed and the information gathered fed back to the maternity sector to inform clinical education and policy.

“These audits contain valuable information which can help us to provide even better care for the mums of tomorrow,” says Dr Coleman.

“Making this worthwhile programme a permanent part of our maternity quality and safety activities is a credit to the clinicians involved and their commitment to improving care.”

The Audit programme has been a joint effort, led by the University of Otago with support from the Ministry of Health, NZ Health Research Council and DHBs.

The Ministry will invest $2 million over the next four years into the audit programme which will sit under the Health Quality and Safety Commission.

To read the full news story and for contact details, go to:  http://www.hqsc.govt.nz/news-and-events/news/2050/

Forty-two articles were included. "The reported incidence of FTR varied between 8.0 and 16.9%. FTR was inversely related to hospital volume and nurse staffing levels. Delayed escalation occurred in 20.7–47.1% of patients and was associated with greater mortality rates in 4 studies (P < .05). Causes of delayed escalation included hierarchy and failures in communication. Of five interventional studies, two reported a significant decrease in intensive care admissions (P < .01) after introduction of escalation protocols; only 1 study reported an improvement in mortality".

The authors discuss the implications of these findings, including for the development of interventions.

To read the full abstract, and for information on how to access the full text, go to: http://www.sciencedirect.com/science/article/pii/S0039606014007132 or contact your DHB library, or organisational or local library for assistance.

Johnston, M.J., et al. (2015). A systematic review to identify the factors that affect failure to rescue and escalation of care in surgery. Surgery, 157(4), 752-763.

Seven studies were included, describing five different interventions: participation of a clinical pharmacist in a clinical team, introduction of a computerised physician order entry system, implementation of a barcode medication administration system, use of a structured prescribing form and implementation of a check and control checklist in combination with feedback.

The authors note that, although some interventions showed a decrease in MEs, the results are not consistent, and none resulted in a significant reduction in patient harm. They conclude that current evidence is limited and comparative studies with robust study designs are needed.

This article is available to read in free full text at:  http://dx.doi.org/10.1002/14651858.CD006208.pub3

Maaskant JM, Vermeulen H, Apampa B, Fernando B, Ghaleb MA, Neubert A, Thayyil S, Soe A. (2015). Interventions for reducing medication errors in children in hospital. Cochrane Database of Systematic Reviews 3, CD006208.

An audit of 3291 patient records at two academic teaching hospitals in Sydney was undertaken to identify prescribing errors and evidence of their detection by staff. Medication administration errors were identified from a direct observational study of 180 nurses administering 7451 medications. Severity of errors was classified. Those likely to lead to patient harm were categorized as ‘clinically important’.

A total of 12 567 prescribing errors were identified at audit. Of these 1.2/1000 errors (95% CI: 0.6–1.8) had incident reports. Clinically important prescribing errors (n = 539) were detected by staff at a rate of 218.9/1000 (95% CI: 184.0–253.8), but only 13.0/1000 (95% CI: 3.4–22.5) were reported. 78.1% (n = 421) of clinically important prescribing errors were not detected. A total of 2043 drug administrations (27.4%; 95% CI: 26.4–28.4%) contained ≥1 errors; none had an incident report. Hospital A had a higher frequency of incident reports than Hospital B, but a lower rate of errors at audit.

The authors conclude that prescribing errors with the potential to cause harm frequently go undetected. Reported incidents do not reflect the profile of medication errors which occur in hospitals or the underlying rates. This demonstrates the inaccuracy of using incident frequency to compare patient risk or quality performance within or across hospitals. New approaches including data mining of electronic clinical information systems are required to support more effective medication error detection and mitigation.

This is an open access article and can be read in free full text at:  http://dx.doi.org/10.1093/intqhc/mzu098

Westbrook, J.I., et al. (2015). What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. International Journal for Quality in Health Care, 27(1), 1 - 9

The latest issue of the Health Quality & Safety Commission's e-update for the period 16 February to 8 March 2015 is now available online.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.jhin.2015.02.004 or contact your DHB library, or organisational or local library for assistance.

Otter, J.A. (2015). What’s trending in the infection prevention and control literature? From HIS 2012 to HIS 2014, and beyond. The Journal of Hospital Infection, 89(4), 229–236

The Commission, Hand Hygiene New Zealand (HHNZ) and the Surgical Site Infection Improvement (SSII) programme provided updates and engaged with participants in discussions on regional networking, and maintaining and sustaining quality improvement at a local and regional level. They also discussed effective ways of using data to support practice change, consistent use of surveillance definitions and evidence-based interventions.

Karen O’Keefe, First, Do No Harm clinical lead, provided participants with an overview of the role of First, Do No Harm, and the activities they are already supporting to reduce healthcare associated infections in the Northern region. A key focus of the meeting was how to support the transition from centrally lead to regionally coordinated hand hygiene improvement initiatives. Louise Dawson, national Hand Hygiene Coordinator, with Karen O’Keefe and Dr Joshua Freeman, clinical lead HHNZ, led an interactive session using frontline ownership techniques on building existing networks and leading local improvement. Clear purpose, cooperative approach, patient-centred, shared goals, and communications emerged as the key components for a sustainable, effective network.

Improvement activities already underway in the region were a highlight of the meeting. Karen Bennett, Northland DHB, gave an excellent presentation on the innovative approach their DHB has taken to improve local hand hygiene practice using:

• a multi-pronged approach with a focus on all professional groups and levels
• a range of ideas and resources – polo-shirts, wall art, ‘thumbs’ (agar plating) studies
• champions at all levels of the organisation
• science of improvement methodology – including PDSA cycles to plan, test, and implement improvement
• patient involvement.

Two important aspects of the Northland DHB approach have been to gain senior sponsorship for action, and to set an aspirational target of 90 percent – 10 percent above the national goal of 80 percent by June 2015. In addition frontline ownership and accountability with local teams is supported by the DHB's ‘Responsibility to Remind’ campaign, and a refreshed hand hygiene policy which requires staff to support one another in achieving consistently good hand hygiene practice. Progress is tracked and reported at the DHB level, with life-size cut-outs of hand hygiene champion Dr David Hammer, clinical microbiologist, driving home the message in wards and departments.

Waitemata DHB also shared the hand hygiene video they have created as a resource for frontline staff. It was specifically developed to improve the focus on hand hygiene among clinical staff, and specifically among doctors. It was developed and filmed with Waitemata DHB doctors as part of an education strategy to work with key audiences to tailor hand hygiene messages. The video can be accessed by clicking the link below.

Sourced from the HQSC website: http://www.hqsc.govt.nz/our-programmes/infection-prevention-and-control/news-and-events/news/2029/

The video, which is featured on the DHB's website (www.southerndhb.govt.nz), profiles support staff, senior managers, doctors, nurses, allied health and patients sharing their thoughts on the importance of having an open, transparent and proactive culture of direct feedback, reporting learning and improving. A culture in which staff "speak up" readily about safety issues and report perceived risks.

Talking about the video, Tina Gilbertson, Director of Quality commented, "the video is part of a larger programme of initiatives designed to further progress our safety culture; one that puts staff at the centre of patient safety and recognises the
pivotal role they have in preventing harm." 

Mrs Gilbertson says that the DHB wants staff to feel confident about sharing their experiences and this new video showcases a variety of staff showing their support
for an open approach to information sharing, recognising that patient safety is everybody's responsibility.

The launch of the new video has been timed to coincide with the imminent roll out of the new South-Island wide electronic risk management system - Safety 1st - which is due to "go live" in Southern Hospitals on the 3rd March.

You can watch the video here.

The authors conclude that, "despite the widespread use of repositioning as a component of the management plan for individuals with existing pressure ulcers, no randomised trials exist that assess the effects of repositioning patients on the healing rates of pressure ulcers. Therefore, we cannot conclude whether repositioning patients improves the healing rates of pressure ulcers. The effect of repositioning on pressure ulcer healing needs to be evaluated".

This paper is available to read in free full text at:  http://dx.doi.org/10.1002/14651858.CD006898.pub4

Moore ZEH, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews, 1, CD006898. 

The February 2015 edition of Medication Safety Watch is now available online. This bulletin is for health professionals and health care managers working with medicines or patient safety. It contains information about preventing harm from medication errors; Open for better care; Medication Safety campaign one steps; Safe use of opioids collaborative; and Incidents and cautions.

To find out more, go to:  https://www.gov.uk/government/news/plans-for-new-legal-protection-for-nhs-whistleblowers

In this issue:

Waikato Hospital’s New Born Intensive Care Unit (NICU) leaves no room for bugs to enter their ward. Looking at vulnerable babies through a window is history – the hands-on approach has made the practise of hand hygiene the number one priority for all.

Doctor Robert Cortesi summarises how helpless young babies are – “the result can be catastrophic, rather than just getting a little sick.”

NICU charge nurse manager Christine Woolerton states that hand hygiene is part of the unit’s culture – “hand hygiene is engrained in everything we do.”

“Hand hygiene saves lives. Sepsis kills babies, bugs kill babies. They’re very fragile and hand hygiene saves their lives.”

Waikato District Health Board has recently introduced a new staff award that recognises where a patient safety initiative has been identified, implemented, and demonstrated ongoing success and sustainability.

Waikato Hospital’s NICU and Thames Hospital’s Chemotherapy Unit are the joint winners of the first Sustaining Excellence in Patient Safety Award. They both won the award for impeccable hand hygiene.

The awards were presented on 18 February at the Waikato DHB Board of Clinical Governance meeting.

Christine believes their success comes down to having a team who is completely dedicated to hand hygiene.

“We’ve always had that high standard; we’ve always been at the top of the hospital for hygiene.

“There are 18 gel containers within reach in one nursery; there is no excuse for not using it,” comments Christine.

NICU staff constantly think of creative ways to remind each other about the hand hygiene standards they need to meet, creating fun coloured laminated messages and sticking them everywhere is just one example.

“We [staff] are all extremely conscious of what we are doing because we are caring for babies – other people’s babies.”

Another important rule NICU enforces is “bare below the elbows, no jewellery allowed.”

With two staff members auditing the floor, and five or six champions for infection control in the unit, forgetting to gel your hands is a big no-no.

The number of children and young people who die in New Zealand each year has more than halved since 1980, a new report shows.

In 2013, 515 New Zealanders aged 28 days to 24 years died, according to the 10th Data Report of the Child and Youth Mortality Review Committee, covering 2009–2013. This compares with 1334 deaths in 1980.

The trend continued during the years focused on in the report, released under the umbrella of the Health Quality & Safety Commission, with 674 deaths in 2009, 620 in 2010, 632 in 2011 and 601 in 2012.

In total, 3042 children and young adults died during 2009–2013.

The largest single cause of death was suicide. There were 645 suicides in total, including 316 aged 20–24, 293 aged 15–19 and 35 aged 10–14. More than twice as many males than females committed suicide – 464 compared with 181.

Transport-related incidents accounted for 572 deaths (460 of them involving those aged 15–24), sudden unexpected death in infancy (SUDI) for 228, drowning for 92, assault for 77 and unintentional poisoning for 53. There were 1183 medical-related deaths.

The report shows Maori have the highest mortality rates, followed by Pacific people, and that mortality rates increase significantly with deprivation.

Dr Felicity Dumble, chair of the Child and Youth Mortality Review Committee, says: ‘The reduction in deaths is great news reflecting the success of a number of initiatives improving the health and safety of our children and young people. However, any avoidable death of a child or youth is premature and a tragedy. We still need to use this information to determine where to focus our future efforts.’

The Commission is currently trialling a Suicide Mortality Review Committee, with Maori youth one of its focuses as it seeks to identify contributing factors and patterns of suicidal behaviour and key intervention points for suicide prevention.

In addition to the 3042 New Zealanders, 67 non-New Zealanders died in the country during 2009–2013, including 17 as a result of the 22 February 2011 Christchurch earthquake.

To read the full 10th Data Report, go to: http://www.hqsc.govt.nz/our-programmes/mrc/cymrc/publications-and-resources/publication/1311/

To find out more and watch the video, go to:  http://www.open.hqsc.govt.nz/medication/publications-and-resources/publication/1993/

Twenty-six papers were included from 11 countries, with one multi-national study. Key themes included clinical workload, work setting, the registered nurses’ characteristics, and their lived experience of work. 

The authors conclude that the "... interplay between factors that influence behaviour were poorly accounted for within the selected studies. It is proposed that a shift away from error as an event to a focus on the relationships between the person, the environment and Registered Nurse medication administration behaviour is needed to better understand medication administration error".

Now available to read in free full text at: http://dx.doi.org/10.1016/j.ijnurstu.2014.07.003 

Barriball, K.L., et al. (2015). Factors contributing to registered nurse medication administration error: A narrative review. International Journal of Nursing Studies, 52(1), 403–420.

They conclude from their analysis of results that "risk stratification of geriatric adults following ED care is limited by the lack of pragmatic, accurate, and reliable instruments. Although absence of dependency reduces the risk of 1-year mortality, no individual risk factor, frailty construct, or risk assessment instrument accurately predicts risk of adverse outcomes in older ED patients. Existing instruments designed to risk stratify older ED patients do not accurately distinguish high- or low-risk subsets. Clinicians, educators, and policy-makers should not use these instruments as valid predictors of post-ED adverse outcomes". The authors discuss the implicaitons of their findings. 

This article is available to read in free full text at:  http://dx.doi.org/10.1111/acem.12569

Carpenter, C.R., et al. (2015). Risk factors and screening instruments to predict adverse outcomes for undifferentiated older emergency department patients: A systematic review and meta-analysis. Academic Emergency Medicine, 22(1), 1–21.

Ten articles were included (with a level of evidence graded as low to moderate). None reported an adverse effect on perioperative morbidity or mortality. Length of stay was decreased, and readmission rates were unchanged in six of seven studies that compared these outcomes.

The authors conclude that "... ERAS protocols may be implemented in pancreatic surgery without compromising patient safety or increasing [length of stay]" They go on to say that programmes should be based upon the best available evidence, and trials involving multiple centres should be undertaken.

Now available to read in free full text at: http://dx.doi.org/10.1111/hpb.12265 

Kagedan, D. J., Ahmed, M., Devitt, K. S. and Wei, A. C. (2015), Enhanced recovery after pancreatic surgery: a systematic review of the evidence. HPB, 17(1), 11–16.

"No published papers were identified for inclusion in the review. Fifteen patient safety investigative frameworks were collected and analysed. Twelve of the retrieved frameworks were intended for the investigation of community-acquired pressure ulcers; seven of which took account of the setting where the ulcer originated as being the patient's home". The authors conclude that there is "...evidence to suggest that many of the root cause analysis frameworks used to investigate community-acquired pressure ulcers in England are unsuitable for this purpose". The authors discuss the implications of these findings.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/jocn.12644 or contact your DHB library, or organisational or local library for assistance.

McGraw, C. and Drennan, V. M. (2015), Evaluation of the suitability of root cause analysis frameworks for the investigation of community-acquired pressure ulcers: A systematic review and documentary analysis. Journal of Clinical Nursing, 24: 536–545. 

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/imj.12604 or contact your DHB library, or organisational or local library for assistance.

Beran, R. G. (2014), Mandatory notification of impaired doctors. Internal Medicine Journal, 44: 1161–1165.

A systematic review and thirty articles were included in a network meta-analysis. "There was a reduced hazard of progression to Type 2 diabetes mellitus associated with all interventions versus standard lifestyle advice; glipizide, diet plus pioglitazone, diet plus exercise plus metformin plus rosiglitazone, diet plus exercise plus orlistat, diet plus exercise plus pedometer, rosiglitazone, orlistat and diet plus exercise plus voglibose produced the greatest effects".

The authors discuss the implications of these findings and note that "adverse events and cost of pharmacological interventions should be taken into account when considering potential risks and benefits".

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1016/j.diabres.2015.01.027 or contact your DHB library, or organisational or local library for assistance.

Stevens, J.W., et al. (2015). Preventing the progression to Type 2 diabetes mellitus in adults at high risk: A systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions. Diabetes Research and Clinical Practice, 107(3), 320–331.

The quality accounts are available to read at:  http://www.northlanddhb.org.nz/Portals/0/Communications/Publications/E38_NDHB_Quality_Accounts_14_FINAL_LRes.pdf

 The Quality Accounts showcase progress to date in improving service delivery and health outcomes for our population; highlighting our successes, what the DHB has learned and our future improvement goals.

The Quality Accounts are available to read in full text at: http://www.westcoastdhb.org.nz/publications/quality/WCDHB-QualityAccounts-Jul2013-Jun2014.pdf

This paper has been prepared with the assistance of Associate Professors Marius Rademaker (Hamilton) and Pablo Fernández-Peñas (Sydney) and is intended as a resource for healthcare professionals involved in the field of oncology.

The review is attached below.

Includes information on health targets; quality and safety markers; patient experience and consumer feedback; serious adverse events; elective services; maternal and infant; child and youth health; health of older people; primary care; medical and acute care; and mental health.

The Quality Accounts are available to read in full text at:   http://www.scdhb.health.nz/news/key-documents/quality-accounts.html

It outlines their commitment to improving services and to be transparent and accountable to patients, their families and the public, as well as to stakeholders and colleagues across the health sector. The report provides examples of quality and safety initiatives underway at the DHB.

The report is available at: http://www.tdh.org.nz/assets/Documents/Reviews-and-plans/Quality-Account-2013-14.pdf

Tairāwhiti District Health (TDH) completed a number of projects in the last year to improve healthcare for the people of Tairāwhiti and these are covered in the 2013/14 Quality Account that was released just prior to Christmas.

The account shows that TDH met or exceeded five of the six Ministry of Health targets. The only target not met was providing stop smoking advice in primary care. The target is 90 percent and in Tairāwhiti, 86 percent of smokers received advice. That is an increase of nearly 30 percent on the previous year.

The account also covers what TDH is doing to prevent falls – the most common risk to patient’s safety, reduce hospital acquired infections, make surgery even safer, prevent Sudden Unexpected Death in Infancy, reduce the number of mental health patients that are secluded as well as detail of the learnings from the two serious adverse events that occurred last year.

District Health Boards produce Quality Accounts to report on the quality of the services they provide. “They are a snapshot of the areas where services are continually improving, areas where we would like to be doing better, and areas where we are intending to focus in the year ahead, says Chief Executive Jim Green. “Quality Accounts are designed to be published alongside financial accounts to demonstrate that quality and patient safety is of equal value to organisations like TDH.”

“We are an organisation that only exists because people need to be supported to gain optimal health. As a funder and provider of services we are geared to meet this need. That is not enough however. We need to know that the care provided in our district, is to a standard that meets the expectations of our communities. Our Quality Account should make it clear to the community just what they can expect from TDH, and what we will not tolerate and take action to correct.”

The TDH Board regards quality as the number one priority, says Board Chair David Scott. “Close scrutiny and discussion of the quality indicators is a frequent feature at monthly Board meetings. The Quality Account indicates the time and energy invested by our dedicated staff with pleasing improvements shown.”

Responsibility for managing patient quality and risk lies with the Director of Nursing and Midwifery, Sonia Gamblen “About 12 years ago I started asking myself and the people with whom I worked ‘Why do patients have such differing experiences of health care? Why does patient “A” have a good experience and patient “B” have a completely different experience?’ I have seen marvelous patient outcomes, but also patients suffering various forms of harm as a result of their hospital experiences. While I firmly believe none of the harm was intentional, it was often not seen as preventable. The change in thinking – to consider and put in place measures that prevent adverse patient outcomes and promote safe expert care – makes it an exciting time to be working in health care.”

TDH’s key areas of focus in the year ahead are meeting or exceeding national health targets, improving patient safety, improving connections between primary and secondary care, improving access to clinicians for those living in remote communities, improving TDH’s facilities to treat cancer and addressing Tairāwhiti’s high level of obesity and diabetes.

“We are making excellent progress,” says Mr Green, “but there is still much work to be done and I am grateful for the efforts of the staff dedicated to doing it.”

If you have any feedback about this Quality Account and whether they provide relevant and useful information on the quality of health services being delivered in Tairāwhiti please use the feedback form.

Read Tairāwhiti District Health’s 2013/14 Quality Account

They aim to:

• increase awareness of the diverse factors that influence AMR
• aid research groups in identifying issues for investigation
• aid in policy development

The maps were published in 2014 by the Department of Health, Public Health England, Department for Environment, Food & Rural Affairs, and the Veterinary Medicines Directorate.

To download the document in free full text, go to:  https://www.gov.uk/government/publications/antimicrobial-resistance-amr-systems-map

Opioids are used for managing pain, and the Atlas shows significant differences in use between DHBs. To some extent, this will be because DHBs have different populations, with different needs. However, the data is a prompt to DHBs to see where they sit and find out more about why differences exist.

To read the full background to the Opium domain, go to the HQSC website:  http://www.hqsc.govt.nz/news-and-events/news/1949/

To access the bulletin, go to:  http://www.hqsc.govt.nz/our-programmes/medication-safety/news-and-events/news/1932/

To read a news article about the data and for a link to the latest quality and safety markers, go to:  http://www.hqsc.govt.nz/news-and-events/news/1913/

The Quality Account includes: 

• Lakes DHB’s first Patient Experience Week which actively sought feedback from patients who had recently been in hospital and received some candid and thoughtful views on their experience during their stay 
• The Woman Child and Family Service’s child health consumer reference group which provides suggestions as to how to improve services in this area 
• Improvement across the six Quality and Safety Markers including hand hygiene 
• Safe and Standardised Clinical Handover which has become embedded in the way things are done at Lakes DHB 
• Awhi midwives, a new model of maternal and child health integrated service provision which is proving to be well accepted and popular in the Turangi community with some very good clinical results 
• Community pharmacists working on a new model of care that puts the service user at the centre. 

The report for 2013/14 Quality Account aims to show Lakes DHB’s position nationally by reporting on the health targets and quality and safety markers and compares results across the country. It reports on serious adverse events and actions taken to minimise the events reoccurring. 

To download the document, go to:  http://www.lakesdhb.govt.nz/Resource.aspx?ID=30014

The December 2014 edition of Let's Talk Triggers is now available on the Health Quality & Safety Commission's website. This quarterly newsletter from the Commission's Global Trigger Tools programme contains updates, trigger tool tips, featured articles and other items on patient safety. 

It has also highlighted some of the feedback and experiences of care by its patients and consumers of its hospital, community health, and primary care services.

The Quality Account is available to read in full text at:  http://www.midcentraldhb.govt.nz/Publications/AllPublications/Pages/2013-14%20Quality%20Account.aspx

Eligible participants were 18 years of age or older, from a neurology or orthopaedic ward and had been admitted to hospital at least 24 hours prior to enrolment in the study. A questionnaire including fixed and open-ended responses was administered by researchers to 51 participants (mean age of 65 years; three quarters were orthopaedic surgical patients).

Eighty-six per cent of participants understood the concept of pressure injury and 80% agreed that patients have a role in PIP. Participants nominated the following PIP strategies that could be undertaken by patients: Keep skin healthy; Listen to your body and Looking after the inside. Strategies required for patient participation in PIP were represented by three themes: Manage pain and discomfort; Work together; Ongoing PI education.

The authors conclude that, to ensure successful participation in PIP, patients require education throughout admission, management of pain and discomfort and a supportive and collaborative relationship with health care staff. Health professionals should identify patient ability and motivation to prevent pressure injury (PI), work in partnership with patients to adhere to PIP, and ensure that PIP actions are facilitated with appropriate pain relief.

This is an open access article and is available to download and read in free full text at:  http://dx.doi.org/10.1186/s12912-014-0041-y

McInnes, E., et al. (2014). The role of patients in pressure injury prevention: A survey of acute care patients. BMC Nursing, 13:41.

Contents include:

Priority One: Continue to keep our patients safe during their care

• Reducing falls resulting in harm
• Health Care associated infections
• Hand Hygiene
• Reducing perioperative harm
• Reducing Medication Errors
• Reducing Hospital acquired pressure injuries
• Seclusion Minimisation in Mental Health

Priority Two: Continue to improve the quality of end of life care

Patient Outcomes

Priority Three: Continue to work to improve our escalation process when a patient’s condition deteriorates

Patient Experience

Priority Four: Improve our customer care and responsiveness to patient needs

Our focus for 2014/2015

Priorities for improvement and why we chose them

Capability Development

The report is available to read online at: http://waikatodhb-ebooks.co.nz/qualityreport/index.html

Minimising the risk to patients from falls, infections, surgical errors and medication issues has been the focus of the Health Quality and Safety Commission (HQSC) and is reflected in the activities that have taken place during the month. Hand Hygiene has also been a focus of the Commission and Tairawhiti District Health because hand hygiene is one the best ways to stop the spread of infection. Staff at Gisborne Hospital are regularly audited against the World Health Organisation’s five moments of good hand hygiene practice.

To read the full media release from Tairawhiti DHB, go to:  http://www.scoop.co.nz/stories/GE1411/S00121/clean-hands-tested-during-patient-safety-month.htm

Today is World Wide Stop Pressure Injury Day, and Waikato DHB is marking it with information for staff and public and an update on the DHB’s own project to reduce pressure injuries in hospital.

Sometimes called pressure ulcers or bed sores, pressure injuries are caused by persistent pressure on a localised area of skin. The pressure obstructs blood flow to the skin and the skin dies, and the area below it can become infected.

Pressure injuries are often on a person's bottom, heels, elbow or base of the spine, but there are many other 'danger spots' as well. People confined to bed are particularly prone to them, because they are less able to move themselves to relieve pressure.

“The key is to identify the danger before it starts or to catch it as early as possible,” says Quality and Patient Safety assistant group manager Mo Neville.

“Our focus is on prevention and management. That includes making members of the public more aware of situations where they or a family member might be at risk of a pressure injury.

“We have some straightforward advice on our website that uses the word SKINS to remind people of the things to look out for.”

S – Surface: Make sure you are on a supportive surface
K – Keep moving: Change your position often
 I –  Incontinence: Keep dry and clean
N – Nutrition: Eat healthily and drink frequently
S – Skin Inspection: Check for discolouration and soreness

Hospital staff must also be ultra-alert about pressure injuries, because many patients have restricted movement and medical conditions that make healing more difficult. In some cases, equipment used to treat patients can become a source of pressure, if not properly managed.

Waikato DHB began a pilot project on three Waikato Hospital wards in April last year that have patients at higher risk of developing pressure injuries because of their medical condition or age. The project focused on staff education, and a recent six-month evaluation indicated higher staff awareness and reporting of pressure injuries and no stage 3 or 4 (more advanced level) hospital acquired pressure injuries.

While the results are encouraging, Ms Neville says it will take a rollout of the project across the organisation next year to really see how the DHB is progressing. “When we have very small patient numbers, the results can fluctuate. Larger numbers will give us better tracking of our progress.”

Feedback from staff on the pilot project wards is very positive. Karen Nixey, a nurse educator on Ward M14 says the project has “focused nurses’ attention on a really important area of patient care.” Raewyn Lee, charge nurse manager of Ward OPR4  says “the pressure injury pilot project is a great quality initiative that guides nurses’ practice in preventing and managing pressure injuries.“

A suite of track and trigger ‘Observation and Response Charts’ were designed in Australia. This paper reports initial clinical user experiences and views, discussed in focus groups following implementation of these charts in eight trial sites (adult general medical-surgical wards).

This second edition provides useful information about using the GTT, including managing data, standard operating procedures, reporting, triggers, performance indicators, and identifying opportunities for improvement.

The guide is available to download on the HQSC website:  http://www.hqsc.govt.nz/publications-and-resources/publication/690/

The NZPhvC successfully piloted a web-based, voluntary and anonymised medication error reporting programme (MERP) designed to reduce patient harm by gaining a better understanding of the causes and likely prevention strategies for medication errors in primary care. The MERP will now be rolled out in stages to expand and promote use in primary care.

To read the full story on the HQSC website, go to: http://www.hqsc.govt.nz/our-programmes/medication-safety/news-and-events/news/1861/

Members of the South Island Alliance’s Quality and Safety group have pledged their support for the inaugural National Patient Safety Week (3rd to 9th November) and are encouraging South Island health care providers and staff to use this week as a chance to put patient safety ‘top of mind,’ and to keep building a just culture within South Island health care settings.

The week is being coordinated by the Health Quality and Safety Commission (HQ&SC) as part of its ’Open for Better Care’ programme. The national week is intended to create focus, energy and momentum, and raise awareness of the importance of patient safety through a concentrated burst of activities over five days. These include:

• HQ&SC hosted workshops on reducing perioperative harm with human factors specialist Professor Jim Bagian. Dr Bagian is a US-based human factors experts who lists among his qualifications and achievements: astronaut, anaesthetist, engineer, mountaineer, snow-and-ice rescue techniques instructor, freefall parachutist, and pilot of propeller and jet aircraft, helicopters and gliders. He is currently Director of the Center for Healthcare Engineering and Patient Safety at the University of Michigan. The Dunedin based workshop will be attended by health care staff across the South Island.
• Let’s PLAN for better care – a health literacy initiative for primary care settings, providing resources to help patients prepare for their visit to the GP.
• A celebration of “Open for better care” in secondary care, continuing to raise awareness of the importance of providing safe, quality care through a series of health settings based events.
• Release of Patient Experience Survey results – the HQ&SC will be releasing the national results from the first survey on Tuesday 4 November.

Mary Gordon, Chair of the Quality and Safety Group said that the national week provided a valuable opportunity for South Island health providers: “There are numerous initiatives underway currently designed to improve patient safety outcomes, to reduce risk and hazard and improve quality of care. This week gives providers a valuable platform to help raise awareness of these initiatives, to educate the public and engage staff, and to help keep momentum building to deliver improved safety outcomes.”

The South Island Alliance’s Quality and Safety Group is a collaboration of health professionals and consumers from across South Island DHBs and primary care who work together to co-ordinate initiatives that improve quality and safety for South Island patients and providers.

The Q&SSLA is working on several key projects to improve safety outcomes in the South Island, one of these is a new integrated risk and incident management system (currently known as RL6), which is currently in development for South Island DHBs and is due to commence roll out from November 2014. The system promises to support improved patient safety outcomes and a reduction in all types of risk for patients, staff and visitors. Its introduction will also support each DHBs commitment to providing a ‘just’ culture; one that recognises that adverse events and incidents will happen from time to time, and that through promoting a transparent and open culture of reporting and information sharing, staff will continue to learn and there will be ongoing improvement and refinement of patient care.

Every serious adverse event represents someone who has suffered life-changing harm or has died in the care of the health system.

Hawke’s Bay District Health Board Chief Medical Officer-hospital John Gommans said the board and hospital staff took their responsibility for each adverse event seriously and were determined to continually work on improving the quality of care provided to patients.

Dr Gommans said patients who experienced harm during health care, should expect that their case would be reviewed by an experienced team to find out what happened and what could be done to prevent the same thing from happening to someone else in the future.

While serious adverse events were very uncommon with over 34,000 admissions to Hawke’s Bay Hospital each year, each event needed to be reviewed and understood, so that the care provided to all can improve, he said.

Preventing falls was a major focus to preventing adverse events and this year Hawke’s Bay DHB reported seven falls that resulted in injury and two collapses that resulted in injury through the Serious Adverse Events report.

Dr Gommans said Hawke’s Bay District Health Board’s Chief Nursing Officer Chris McKenna chaired a falls minimisation committee, which recommended strategies for system improvement to reduce harm from falls both in hospital and in the community.
In Hawke’s Bay Hospital over $70,000 had been spent on a variety of measures to reduce harm from falls including systematic assessment of risk of the elderly within 24 hours of admission, a visual signalling system at the bedside of patients that alerted staff and visitors of a patients risk, alert monitors and specialised beds.

Dr Gommans said a Vitamin D prescribing programme was in place in the aged care sector with 80 percent of clients prescribed Vitamin D to help make bones stronger and improve muscle strength that would improve balance and reduce injury from falls amongst the elderly.

In the community a partnership with the district health board, Health Hawke’s Bay and ACC was also meeting regularly to focus on preventing falls in the community and making inroads with awareness campaigns.

“We have a real focus on making sure all falls are reported so we can learn from them and put in place better preventative measures to stop similar falls happening again.
“We know we have a lot to improve on so we have made it part of a formal reporting requirement to Hawke’s Bay’s Clinical Council, and it is also a part of national reporting to the Health Quality & Safety Commission through the district health boards annual Quality Accounts. All falls are reported to the Clinical Nurse Managers and reviewed to make a safer hospital.

The SAE report published each year was a reminder to everyone who worked in health that no system was perfect. “We all need to review, learn and evolve to meet the needs of our patients to prevent harm,” Dr Gommans said.

ADDITIONAL INFORMATION:

• Hawke's Bay DHB SAE Report
• Serious Adverse Event Report
• HQSC Media Release
• HQSC Questions and Answers

New Zealand hospitals are about to strengthen their defences against multi-resistant bacterial infections with the funding of a new antibiotic.

From 1 November PHARMAC will add ceftaroline fosamil to the list of medicines funded in DHB hospitals. Ceftaroline is a fifth-generation cephalosporin, an updated version of a long line of effective anti-bacterials. It will be particularly targeted at people exposed to multi-resistant strains of bacterial infections, more commonly referred to as `superbugs’.

Deputy Medical Director Dr Dilky Rasiah says the listing of ceftaroline is timely, given the high level of concern internationally around growing bacterial resistance to antibiotics.

Dr Rasiah says ceftaroline will be preserved as a ‘last-line’ defence against multi-resistant organisms, to help protect its usefulness.

“Multi-resistant bacteria are now a reality, so it’s important that we have more tools at our disposal to deal with them,” she says. “We continue to have an effective range of antibiotics, but every so often we encounter a strain or type of bacteria that requires several different types of antibiotic to treat it, or people can find it hard to take other antibiotics.”

“It’s a bit like links in a chain, and what we are doing with this decision is adding another link to that chain.”

“As well as making funding available, part of PHARMAC’s role is in antimicrobial stewardship – working alongside other agencies and health professionals to ensure that these important medicines continue to be effective for the future.”

“That is why we are being very careful with how this new option will be targeted.”

In New Zealand, rates of multi drug-resistant infections are monitored through ESR. Data on rates of infection in New Zealand are published on the ESR website.

ESR Clinical Microbiologist Dr Deborah Williamson says it is important New Zealand confronts the challenge of antimicrobial resistance, one of the biggest man-made public health threats of modern times.

"New Zealand is fortunate to have a coordinated programme of antimicrobial resistance surveillance that is based at ESR.

"We have recently been involved in antimicrobial susceptibility testing of ceftaroline in New Zealand, and believe it will be a valuable new drug," Dr Williamson says.

A Health Quality and Safety Commission report shows Canterbury District Health Board remains committed to making its hospitals safer through transparent and open reporting of Serious Adverse Events.

Today (October 30, 2014) the Health Quality and Safety Commission have released: Making Our Hospitals Safer, which summarises the Serious and Adverse Events (SAE) reported by all 20 District Health Boards from July 1, 2013 to June 30, 2014.

In Canterbury there were 56 serious adverse events (CDHB) in the July 2013 to June 2014 year – up slightly on the previous year when there were a total of 47 Serious Adverse Events.

Dr Nigel Millar, Canterbury DHB Chief Medical Officer, says falls continue to dominate SAE's with 35 patients reported to have had a serious fall in our hospital in the 2013-2014 year.

"The Canterbury Health System continues to focus on making our hospitals and community care facilities safer to achieve zero harm from falls by focusing on the three key areas: falls prevention in the wider community; falls prevention in rest homes; and falls prevention for older people receiving care in Canterbury DHB hospitals," Dr Millar says.

In the community and rest homes the Canterbury Community Falls Prevention Programme, which enabled more than 3000 older people to be seen in their own homes, has been reviewed and improved.

"Clients will now have access to a more responsive, clinically- led falls programme, no matter their level of frailty.  All of these people will receive an initial visit including a home hazard check and the most appropriate falls prevention programme will then be delivered."

Dr Millar says the Canterbury DHB is also working with rest homes and primary care providers to ensure that at least 75 percent of residents over 65 years are receiving Vitamin D supplementation. 

"Research suggests Vitamin D supplementation for this group of older people significantly reduces falls and serious harm from falls."

In hospital the Canterbury DHB continues to focus on patient assessment and tailoring falls prevention strategies to meet the needs of individual patients while they are in hospital and for when they return home.

Dr Millar says in August 2013 a Steering Group was introduced to provide oversight and direction across hospitals for the Hospital Falls Prevention Programme.

"This programme aims to reduce falls in hospital and includes routine activities such as the annual Falls Awareness Campaign, reviewing policies, monitoring falls and patient's assessments as well as key projects."

Two current projects are:

• Standardising the falls prevention visual cues across hospitals and care of patients following a fall.  Visual cues can be displayed at the patient's bedside, worn as a bracelet or tagged to patient equipment.  They indicate to family and staff at a glance the level of assistance a patient requires in moving about;

• Ensuring patients have access to appropriate walking aids, this involves identifying the barriers to patients bringing their own walking aids to hospitals as well as looking at the availability of walking aids in hospital.

"At Canterbury DHB our patient focused, clinically led culture supports our commitment to 'zero harm' and continuous quality improvement. 

"All serious adverse events are reviewed through a formal process that involves a multidisciplinary team.  The purpose of reviewing these is to understand underlying causes of the event.  By identifying problems and failures we can learn from them and make our systems safer."

The Health Quality & Safety Commission New Zealand report 'Making Our Hospitals Safer' was released today. This is their eighth report on serious adverse events that have occurred in the country's hospitals in the past year. The report can be accessed via the Health Quality and Safety Commission website.

There were 12 serious adverse events for the West Coast DHB compared to 10 last year.

"Whilst we need to monitor any increase in events, this could be due to a more open and positive reporting culture," outgoing West Coast DHB Chief Medical Officer Dr Carol Atmore says.

"Last year the Health Quality & Safety Commission launched a 'falls initiative' and it could well be that the heightened awareness of falls resulted in more reporting (6 of the 12 incidents were related to falls). We are actively engaged in fall prevention and support the work of the West Coast Falls Coalition."

Dr Atmore stresses it is extremely important to be open and transparent when a patient is harmed while receiving medical care in the public health system. "These events have huge impacts on our patients, their families and on staff. We've found that by encouraging the reporting and investigating process that follows any serious and adverse event, we are able to look at the way we do things, learn from it and reduce the likelihood of a recurrence," she says.

One such example has been the introduction of the ISBAR communication/handover tool across the DHB. ISBAR is an acronym that stands for; I = Identity, S = Situation, B = Background, A = Assessment, R = Request/Recommendation. The ISBAR tool helps improve communication between health professionals and enhances patient safety by reducing the risk of communication errors or omissions between staff. It also ensures handovers are succinct and timely, and that all relevant patient information is conveyed between staff.

The West Coast DHB (together with the four other DHBs in the South Island Alliance) is about to introduce a new Incident Management System. The new system will make it easier for staff to report incidents and lodge complaints to help improve patient safety outcomes.

"Our incident management system encourages a culture that recognises adverse events and incidents will happen from time to time. Through promoting a transparent and just culture of reporting and information sharing, staff will continue to learn and there will be on-going improvement of the quality of patient care," Dr Atmore says.

In a further effort to improve the management and response to adverse events when they happen, a new West Coast DHB Patient Safety Officer role is being established. This role will provide a single point of contact for patients and their families involved in serious and adverse events. The Safety Officer will maintain oversight on investigations following an event, to ensure that the learnings from the event, and feedback to families, are timely. Another initiative to assist in this process has been the provision of "Human Factors" training for WCDHB staff. This approach from an airline safety background aims to improve patient safety.

West Coast DHB Chief Executive David Meates says West Coasters can be assured that the reporting and investigation processes serve to make hospitals safer and lessen the chance of future incidents.

"It's important we take notice of these events to check for underlying systemic issues. Our internal systems are now working better in terms of identifying issues quickly and starting a process to address them. Ultimately, we want people to be able to have confidence that they will receive the healthcare they need from our health system and in the event that something does go wrong, it will be addressed in a timely and efficient manner."

Increased reporting and a growing focus on learning from events are features of the release of the 2013–14 serious adverse events (SAEs) reported by district health boards (DHBs).

The annual report, released by the Health Quality & Safety Commission (the Commission) today, shows a four percent increase in events, with 454 SAEs reported, up from 437 in 2012–13.

Commission Chair Professor Alan Merry says it is encouraging to see the work and resources the health sector has put into getting better at reporting incidents of patient harm.

“Patients who are harmed during health care have a right to understand what happened and to expect that everything possible will be done to prevent the same thing from happening to someone else in the future.”

He says the slight increase in SAEs is likely to reflect the health sector’s increasing commitment to improved reporting of cases.

“We expected the number of SAEs to increase as health providers improved their reporting systems, and that seems to be happening.

“It is also pleasing to see a growing range of providers reporting their serious adverse events, including private surgical hospitals, aged residential care facilities, disability services the National Screening Unit and hospices.”

In 2013–14, falls were the most frequent cause of harm reported by DHBs, making up 55 percent of all cases. Prof Merry says the high number of broken hips following falls in hospital was of continuing concern.

“Ninety-eight people suffered a broken hip in hospital. This rate of harm is far too high, and equates to almost two patients every week suffering such an injury. This is very disappointing given the considerable effort going into reducing harm from falls, and shows this must continue to be an area of high priority for the Commission and the sector.”

Clinical management incidents were the next most frequently-reported event. The 158 reported cases included delays in treatment, assessment, diagnosis and observation. Thirty cases involved medication prescribing, dispensing or administration.

One hundred and four serious adverse events were also reported by non-DHB providers.

Over the next year the Commission will be working with the health sector to increase expertise in learning from adverse events, including providing training in the review of events. There will also be a greater emphasis on dissemination of the crucial lessons learned from reviews of serious adverse events.

Prof Merry says next week’s national Patient Safety Week is an opportunity for health sector staff to increase their event review skills.

“During the week there will be four workshops featuring international patient safety expert Dr Jim Bagian. Dr Bagian will look at the components of a safety system, how to learn from errors and how to improve systems so errors don’t recur.”

For a copy of the full report, a summary document, and questions and answers about the report click on the link below. DHBs have posted their SAE figures on their websites.

Related Publications & Resources

• Publication: Making health and disability services safer - Serious Adverse Events report 2013–14 
  

They found that commonly performed laboratory tests can identify surgical ward patients at risk of early major adverse events, and suggest further studies to assess whether such identification system can be used to trigger interventions that help improve patient outcomes.

To read the full abstract, and for information on how to access the full text, go to: http://dx.doi.org/10.1111/imj.12509 or contact your DHB library, or organisational or local library for assistance.

Kaufman, M., Bebee, B., Bailey, J., Robbins, R., Hart, G. K. and Bellomo, R. (2014). Laboratory tests to identify patients at risk of early major adverse events: a prospective pilot study. Internal Medicine Journal, 44: 1005–1012.

Overall, 114 tools were identified with 26 accrued from grey literature. Most published literature originated from the USA (41%) and the UK (23%) within the last 10 years. Most of the literature addresses the themes of medication error (55%) followed by safety climate (8%) and adverse event reporting (8%). Minor themes included; informatics (4.5%) patient role (3%) and general measures to correct error (5%). The primary/secondary care interface is well described (5%) but few specific tools for primary care exist. Diagnostic error and results handling appear infrequently (<1% of total literature) despite their relative importance. The remainder of literature (11%) related to referrals, Out-Of-Hours (OOH) care, telephone care, organisational issues, mortality and clerical error.

The authors note that many of the tools have yet to be used in quality improvement strategies and cycles such as plan-do-study-act (PDSA) so there is a dearth of evidence of their utility in improving as opposed to measuring and highlighting safety issues. The lack of focus on diagnostics, systems safety and results handling provide direction and priorities for future research.

This is an open access article and is available to read in free full text at: http://www.biomedcentral.com/1471-2296/15/166/abstract

Spencer, R., et al. (2014). Tools for primary care patient safety: A narrative review. BMC Family Practice, 15:166.

In particular, the authors highlight preoperative, intraoperative, and postoperative interventions to combat surgical site infections (SSIs). They contend that current systems in place are often insufficient, and emphasize the benefits of institution-wide adoption of multiple preventive interventions. 

This is an open access article and can be read in free full text at: http://dx.doi.org/10.1186/s13037-014-0042-5

Tsai, D.M. & Caterson, E.J. (2014). Current preventive measures for health-care associated surgical site infections: A review. Patient Safety in Surgery, 8:42.

Available to download and read in full text at: http://www.hqsc.govt.nz/publications-and-resources/publication/1823/

See also: a falls analysis template based on a human factors framework at: http://www.hqsc.govt.nz/publications-and-resources/publication/1824/

The national Open for better care campaign shifts its focus to medication safety today as part of the Health Quality and Safety Commission’s (HQSC) drive to reduce harm from high-risk medicines. A key programme area for the HQSC, the campaign’s focus on medication safety will run from today right through until the end of March 2015.
 
Involving patients and families as well as clinicians in primary, community and secondary care, the campaign aims to raise the awareness of the risk associated with these high-risk medications and promote ways to reduce the associated patient harm.
 
Whanganui District Health Board (WDHB) patient safety and quality manager Lucy Dunlop says the group of medicines that cause the most harm and suffering to patients if errors occur are known as high-risk medicines.
 
“Medication errors and unfavourable drug reactions are a leading cause of patient harm in healthcare settings,” Mrs Dunlop says. “And given up to 60 percent of all adverse drug events are thought to be preventable, Whanganui DHB welcomes the increased focus and awareness the campaign brings.”
 
“As a DHB, we are always striving to improve the care we provide and the campaign is a timely reminder for us to concentrate on these high-risk medicines.
 
“Special attention is needed in all aspects of managing high-risk medicines - prescribing, dispensing, supplying, storing, administering and, importantly, ensuring everything is as it should be for the patient taking the medication.”
 
The annual cost of preventable adverse drug events in New Zealand is estimated to be as much as $158 million, resources that could be used for other services.
 
“The outcomes of patient harm are costly for everyone,” says Mrs Dunlop. “By preventing harm to patients we are able to provide more by not needing to divert much-needed resources away from other areas of care.”
 
The WDHB will highlight the issue of high-risk medications by adding a medication safety focus to their Patient Safety Week activities, 3-9 November.
 
Posters will be displayed around Wanganui Hospital for the length of the medication safety campaign.
 
The HQSC’s Open for better care campaign was originally launched in May 2013 by Associate Health Minister Jo Goodhew with a focus on falls. For more information about medication safety and the Open for better carecampaign in general, please visit www.open.hqsc.govt.nz.