Adj.Prof.Martin D. CulwickMedical Director ANZTADC

Adj.Professor of Information Technology,

Queensland University of Technology

BSc. MB ChB FFARACS FANZCA

Grad.Dip. Commercial Computing

Grad.Cert. Information and Knowledge Management

Grad.Cert Web Services and Component Software

Masters of Information Technology

ANZTADC

Australian and New Zealand Tripartite Anaesthetic Data Committee

ANZTADC Mission Statement

Capture Analyse Disseminate

Detectors EffectorsImproveComplex Adaptive System

To improve the safety and quality of anaesthesia for patients in Australia and New Zealand by providing an

enduring capability to capture, analyse and disseminate information about incidents (made anonymous)

relative to the safety and quality of anaesthesia in Australian and New Zealand.

Data Taskforce 2004

Anaesthetic Incident Analysis

Individual

Departmental

Hospital

State

National

International

Incident monitoring & QA - Current Model

Data Sources

Departmental

Hospital

State

National

Individual Analysis

Analysis

Analysis

Analysis

Analysis

Output

Output

Output

Output

Output

Knowledge

Stovepipes

International Analysis Output

Effectors

Australian &

New Zealand

Tripartite

Anaesthetic

Data Committee

Knowledge

Reports and Bulletins

Guidelines and Algorithms

Publications

PBLDs and Workshops

Simulation

Training & Exam Questions

Improvement

in Practice

ANZTADC

KnowledgeBase

Electronic Devices Mobile – www.anztadc.net/demo/

Mobile Phone Smart Phone Tablet Netbook

Portable Desktop Anaesthesia Machine

Devices attached to and recorded by anaesthesia record keeping programs

All ANZTADC compliant

Progress

Review and Strategic plan – Completed 2008

Specifications and review of existing systems - Completed 2008

Legal opinion sought – Complete 2008 (reviewed 2010)

QA privilege application approved – Completed 2008

Tested existing systems – Completed 2008

Ethics approval applications for pilot sites – 6 completed in 2009

WebAIRS – Pilot Version v1.0 - Released 9/2009 – Completed 8/2010

WebAIRS – Released- 2010 – 28 sites now reporting

Progress Presentations

ANZCA ASM Cairns 2009

ASA NSC Darwin 2009

Medical Education SIG Byron Bay 2009

NZSA ASM Rotorua 2009

ANZCA/NZSA CSM Christchurch 2010

Victoria CME meeting 2010

ASA NSC Melbourne 2010

ANZCA CSM Hong Kong 2011

Future Presentations

Auckland 2011

ASA Sydney 2011

Important Problems/Milestones

Privacy Act

Federal & State Acts

Principles

De-identification/Surrogate identification

Consent

Anonymous identifiers

Ethical review

Agreement with hospitals to forward data

Qualified Privilege

Legal advice was sought at each stage

Disclaimer I am not qualified to give legal advice

This information is based upon legal advice but is not legal advice

Legal advice should be sought for each individual registry

Downloaded 28/5/11 from http://www.privacy.gov.au/materials/types/infosheets/view/6583#npp10

Privacy Act & Consent

Consent – Hospital admission form

Public safety

De-identified

In accordance with the rules of a medical body

Information will be de-identified before release

Ethics committee approval or exemption at each site

Signed agreement for the release of data from each site

Qualified privilege for the collection of data

Consent form

Do we need ethical review?

Ethical review

Ethical Review 2

National Ethics Committee Manages ethics strategy at a national level

Produces the National Ethics Form

Does not give National Ethics Approval

HOMER

One major HREC

Site specific assessment (may be complex and time consuming)

If National Ethics Approval were possible – would only need MoA

Denominator Needed for benchmarking

Detecting incidence and tracking outcomes

Defined Dataset

Must have complete population and follow up missing data

May miss rare events (Data smog)

May not collect some events (outside defined dataset)

Denominator ?

What If?

2 incidents in 1000 cases = incidence of 0.2% (risk of data smog)

Frequency >1% - May be useful

e.g. Difficult intubation, ASA grade, Massive transfusion

Useful for planning, supervision, risk management etc

Rare but critical - ? No

e.g. Early reports of adverse reactions to drugs, Malignant Hyperthermia, Ventilator failure etc

Co-existing/hybrid systems Registry data from Automated Anaesthetic Record

Keeping Systems

Record Incident Yes/No

Some cross checking by using physiological parameters such as SaO2 and BP and drugs used

When incident flagged – the incident recording page opens on the AARK screen

Future scope ? Over next 12-24 months?

Errors – Main Categories

Protected by Australian Govt Qualified Privilege – Not for disclosure without permission

Downloaded 8/5/11 from

http://www.ncbi.nlm.nih.gov/pubmed/20671073?dopt=AbstractPlus

Qual Saf Health Care. 2010 Dec;19(6):e63. Epub 2010 Jul 29.

System-wide learning from root cause analysis: a report from the New South

Wales Root Cause Analysis Review Committee.

Taitz J, Genn K, Brooks V, Ross D, Ryan K, Shumack B, Burrell T, Kennedy P; NSW

RCA Review Committee.

Source: Clinical Excellence Commission, Martin Place, Sydney, New South Wales, Australia.

jonny.taitz@sesiahs.health.nsw.gov.au

Abstract

BACKGROUND: Preventable errors are common in healthcare. Over the last decade, Root Cause

Analysis (RCA) has become a key tool for healthcare services to investigate adverse events and try to

prevent them from happening again. The purpose of this paper is to highlight the work of the New South

Wales (NSW) RCA Review Committee. The benefits of correctly classifying, aggregating and

disseminating RCA data to clinicians will be discussed. In NSW, we perform an average of 500 RCAs per

year. It is estimated that each RCA takes between 20 and 90 h to perform. In 2007, the NSW Clinical

Excellence Commission (CEC) and the Quality and Safety Branch at the Department of Health constituted

an RCA review committee. 445 RCAs were reviewed by the committee in 14 months. 41 RCAs were

related to errors in managing acute coronary syndrome.

RESULTS AND DISCUSSION: The large number of RCAs has enabled the committee to identify

emerging themes and to aggregate the information about underlying human (staff), patient and system factors.

The committee has developed a taxonomy based on previous work done within health and aviation and assesses

each RCA against this set of criteria. The effectiveness of recommendations made by RCA teams requires further

review. There has been conjecture that staff do not feel empowered to articulate root causes which are beyond the

capacity of the local service to address.

CONCLUSION: Given the number of hours per RCA, it seems a shame that the final output of

the process may not in fact achieve the desired patient safety improvements.

Protected by Australian Govt Qualified Privilege – Not for disclosure without permission

Protected by Australian Govt Qualified Privilege – Not for disclosure without permission

Summary

Setting up a national incident recording system

Need for National Ethics Committee

Registries and Voluntary Incident Recording Systems can complement each other

Early and continuous Feedback to those supplying data

Ability to deal with alerts