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.
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