© 2003. Reproduced as licenced to ISQua. 1

Patient Safety Framework

A state-wide multi-facetedapproach to improving patientsafety within South Australianhospitals and health services

Professor Brendon Kearney, Executive Director,Clinical Systems

The Six Dimensions of Quality

Safety

Effectiveness

Appropriateness

Consumer Participation

Efficiency

Access

The framework:

Saf

ety

and

Qua

lity

Fra

mew

ork

Structure

Performance

Frame

Reporting

Frame

• Safety • Effectiveness • Appropriateness • Consumer

Participation • Efficiency • Access • Sentinel events • Level 1 adverse

events / close calls • Indicator results • Accreditation

outcomes

• National • State • Organisational • Human resource • Qualified Privilege • RCA

• Safety Indicators

Info

rmat

ion

Man

agem

ent

/ Ed

uca

tion

an

d t

rain

ing

for

Qu

alit

y / C

omm

un

icat

ion

The Performance Frame- Safety

The Patient Safety Framework describestwo main approaches to monitoring andinvestigating adverse events:

Aggregated data acquisition –Aggregated RCA or CPISingle event notification - RCA

Aggregated data – complaints, audit andquality indicators

• AIMS (aggregated)

• Quality Indicators

• DRG Codes • Audit /

Screening • Complaints • Claims • Aggregated

Events • Trigger

Tools • Data

Warehouse • Accreditatio

n / Standards

• Single incident (eg AIMS report) • Close Call • Sentinel

Events

Data Acquisition

Data Analysis

Data Reporting

Safety Risk Identification

Severity Assessment Code (SAC)

System Issue

IMPROVE QUALITY, REDUCE CLINICAL RISK

Performance Review (criminal or intentionally unsafe act) Coroners Medico-legal

PatientSAfety – Root Cause Analysis and Clinical Practice Improvement

Alerts, Advisory Processes - Communication - local, state, national

CPI / Aggregate RCA (SAC 2 – 4) SAC 1 - RCA

Events:

Reportable Sentinel eventsAdverse EventsClose Calls or Near Misses

Intentionally unsafe actsn Criminal actn Purposefully unsafe actn Act related to alcohol or substance abusen Alleged or suspected patient abuse

© 2003. Reproduced as licenced to ISQua. 2

National Sentinel Events:

Procedures involving the wrong patient or bodypartSuicideRetained instruments of other material requiringfurther surgical procedureIntravascular gas embolism resulting in seriousneurological damage of mortalityHaemolytic blood transfusion reactionMedication error leading to deathMaternal death or serious morbidityInfant abduction or discharge to wrong family

Close Calls:Excellent opportunities for learning andafford the chance to developpreventative strategies and actionsmore so than adverse events.Receive same level of scrutiny asadverse events that result in actualinjuryDefined: events that could haveresulted in an adverse events but didnot, either by chance or through timelyintervention.

Incident Monitoring:

Advanced Incident Monitoring Systemn State-wide roll-outn Centralised solution – fully supported

IRIS – Incident Reporting to ImproveSystemsn Addressing the barriers to reporting

including documentation, time, lack offeedback

n 1800 NOTIFY [call centre]

Root Cause Analysis:

Focus on systems and processes, notindividual performance

Include review of relevant literature

Examine extensively for underlyingcontributing factors

Potentially lead to procedure andsystem modifications

RCA – General Overview

Event occurs [Adverse Event or close call]

Immediate Action

Patient Safety Reporting System

Safety Assessment

Code

Level 1 RCA

Level 2, 3, 4

Aggregate Review

(RCA / CPI)

Identify Causal Statements and Actions

ACTION

EVALUATE

Clinical Practice Improvement:

Provides a methodology for improvingprocesses of care.29 senior clinicians to date haveattended the Brent James CPI Program– Royal North Shore HospitalNegotiating with Ross Wilson to run SAbased program in 2004

© 2003. Reproduced as licenced to ISQua. 3

The Performance Frame -continued:

Quality Performance Indicators:Professor David Ben-Tovim –development of a framework to prioritisePI development in relation to clinical riskand to specify performancecharacteristics

Patient Evaluation of Hospital Services– Epidemiology DHS

Cross Dimensional Issues:

Qualified Privilege – designed to provide onlythe protection necessary to encourage healthcare professionals to take part in qualityassurance and improvement activities. They donot protect all information or documents

Currently developing state administrativeguidelines

Link with national program of work

Cross Dimensional Issues:continued

Event Reporting – State: through DHSsafety and quality website [sentinelalerts], and national via a nationalrepositoryEducation and training for quality –patient safety training, CPI, HumanError, SimulationCommunication / Open Disclosure