Department of Health

October 2003 — June 2005

WA Sentinel Event Report

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Foreword

HereinWesternAustraliawearefortunatetoenjoyworld-classhealth

care.Ourdedicatedhealthworkforceiscommittedtoprovidinghigh

qualityandsafecaretopatients.

Inrecenttimesthedeliveryofhealthcarehasbecomemorecomplex.

Hospitaladmissionsareforshorterperiodsandpatientcareoften

involvestheinputofmanypeopleaswellastheuseofhightechnology

equipment.Itisnotsurprisingthatbecausewearehuman,sometimes

thingsgowrong.Inmostcaseswhenmistakeshappenthepatientis

unharmed.Insomecases,however,theoutcomecanbeserious.

Whenpatientsareharmedbythecarethatisdesignedtohelpthem,it

isnotonlydevastatingforthepatientandtheirfamilybutalsoforthehealthcareprofessionalsinvolved.

TheDepartmentofHealth(WA)isactivelyworkingtomakehealthcaresafer.Ourphilosophyisthatallofus

whoworkinhealthcaremusttakeresponsibilityforourownbehaviouraswellastheactionsofindividualsand

teamswhoworkwithus.Clinicalgovernanceisarecentlydevelopedconceptwhichbringstogetherallthe

activitiesthatdemonstratetoourpatients,thecommunity,governmentandourpeersthatweholdourselves

responsibleforprovidingsafe,highqualityhealthcare.

A key componentof clinical governance inWesternAustralia is the clinical riskmanagement system. This

statewidesystemincludeshealthcareincidentreporting,monitoringandinvestigationsothatwecanlearn

fromourmistakesanddeveloppreventiveplanstoprotectpatientsfromsimilarevents.

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Whenthingsgowrong,ourhealthcareprofessionalsareencouragedtomaintainopenandhonestcommunication

withthepatient.Weprovideinformationaboutwhathappened,whyithappenedandwhatweplantodoabout

it.TheDepartmentofHealth(WA)hasalsocirculatedaguide,Ten Tips for Safer Health Care, toencourage

patientsandtheirfamilies,carersandfriendstobeinvolvedinmakinghealthcaresafer.

ThisinauguralreportonhowweareimprovingpatientcareinWesternAustraliaprovidesasummaryofserious

healthcareincidents,knownassentinelevents,whichwerereportedandinvestigatedfromOctober�003to

June�005.Thedataprovidesuswithapictureofwhattypesofsentineleventsarehappening,howoften,

why,andmost importantlyhowtostopthemfromhappeningagain. Thereportalsooutlinesanumberof

preventivestepsthathavealreadybeenintroducedinourhospitalstomakesurewedeliversafe,highquality

healthcare.

Itisimportantthatwereportonourprogressandbeopenwiththecommunityabouthowwearemakingthe

WesternAustralianhealthsystemevenbetter.IamdelightedtopresentthefirstAnnualreportonsentinel

events.

Dr Neale Fong Director General & Executive Chairman Health Reform Implementation TaskforceNovember 2005

Dr Neale Fong Director General & Executive Chairman Health Reform Implementation TaskforceNovember 2005

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Table of Contents

Foreword 1

Executive Summary 4

2. Background to Patient Safety in Western Australian hospitals 5

3. Health care incident reporting, investigation and monitoring 5 3.1 Incident Reporting 6

3.2 Sentinel Events 6

4. Sentinel Event Program 7

5. Contributing system factors 8

5.1 Procedure involving the wrong patient or body part 10

5.2 Suicide in an inpatient unit 10

5.3 Retained instruments or other material after surgery requiring re-operation or further surgical procedure 11

5.4 Medication error resulting in death 12

5.5 Maternal death or serious morbidity associated with labour or delivery 12

5.6 Other serious event resulting in serious patient harm or death 13

6. The year ahead 17

7. What can consumers do? 18

8. Contact Information 18

APPENDIX ONE 20

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Executive SummarySentineleventshappeninallhealthsystemsaroundtheworld.Theyarerare,preventableeventsthatleadtoorcanleadtoseriouspatientoutcomes.AcrossWesternAustralia,allpublicandprivatelicensedhospitalsarerequiredtoreportthefollowingsentineleventstotheChiefMedicalOfficer:

1. Proceduresinvolvingthewrongpatientorbodypart;2. Suicideofapatientinaninpatientunit;3. Retainedinstrumentsorothermaterialaftersurgeryrequiringre-operationorfurthersurgical procedure;4. Intravasculargasembolismresultingindeathorneurologicaldamage;5. HaemolyticbloodtransfusionreactionresultingfromABOincompatibility;6. Medicationerrorleadingtothedeathofapatientreasonablybelievedtobeduetoincorrect administrationofdrugs;7. Maternaldeathorseriousmorbidityassociatedwithlabourordelivery;8. Infantdischargedtowrongfamilyorinfantabduction;and9. Otheradverseeventresultinginseriouspatientharmordeath.

In accordancewithDepartment ofHealth policy, facilities that report a sentinel eventmust undertake animmediateandthoroughinvestigationtoexaminethecircumstancesandidentifyfactorsthatcontributedtotheevent.Followingtheinvestigation,recommendationsaremadeforstrategiesthatthereportingsitecanputinplacetoreducetheriskofsimilareventsfromoccurringinthefuture.Itisimportantthatthesestrategiesaremonitoredonaregularbasistoensuretheireffectivenessinimprovingpatientsafety.

Thisreportfocusesonthesentineleventsreportedandinvestigatedfromtheimplementationoftheprogramon�October�003to30June�005.Atotalof70sentineleventshavebeenreportedtotheChiefMedicalOfficer.However,twooftheseeventswereconsideredunpreventableleaving68eventseligibleforinclusioninthesentineleventprogram.De-identifiedinformationsubmittedtotheChiefMedicalOfficerwasanalysedtoidentifytrendsandissuesthatmayrequireinterventionatotherhealthservicesacrossthestatethatmaybevulnerabletosimilarincidentsoccurring.

Theanalysisshowedthat��ofthe68eventswerereportedinthe‘otheradverseevents’category.Eleveneventsofthe68eventsinvolvedaprocedureinvolvingthewrongpatientorbodypartandseveneventsinvolvedaretainedinstrumentorothermaterial(suchasswabsorsponges)aftersurgeryrequiringre-operationorafurthersurgicalprocedure.Eventsreportedinthe‘otheradverseevents’categorytypicallyincludedcomplicationsofemergency/resuscitationmanagement,complicationsofsurgeryandhospitalprocessissues.Anoverallreviewoftheinvestigationfindingsdemonstratedthatissueswithpolicies,proceduresandguidelines(forexample, absenceofpolicies,proceduresandguidelines regarding clinicalmanagement)was themostcommontypeofcontributingfactortosentinelevents.Othercommoncontributingfactorsincludedhumanresourceissues,healthinformationissuesandcommunicationproblems.

Analysisoftheaggregatedsentineleventdatasuggeststhatstepstopreventsurgeryonthewrongpatientorwrongbodypartaswellasretainedinstrumentsormaterialfollowingsurgerymayhelptoreducethenumberofreportedsentineleventsinthefuture.TheDepartmentofHealth(WA)hasalertedpublicandprivatelicensedfacilities to the potential risks that contribute to these events and have encouraged them to put in placepreventivestepstostoptheseeventsfromoccurringinthefuture.

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2. Background to Patient Safety in Western Australian hospitalsIn recent times the delivery of health care has becomemore complex. Patients are often cared for by amultidisciplinaryteamusinghightechnologyequipmentandmultiplemedications.Whilemosthealthcareisdeliveredsafelyandappropriately,sometimesthingsgowrong.Ithasbeenreportedinthemedicalliteraturethatapproximatelyone ineverytenhospitaladmissionsallovertheworld isassociatedwithahealthcareincident,someofwhichresultinpermanentdisabilityordeath.Abouthalfofallincidentsarepreventable.

Whilehumanerrorisinevitable,veryfewhealthcareincidentscanbeattributedtoindividualrecklessness,professionalmisconduct,oracriminalact.Itiswidelyacknowledgedthathealthcareincidentsgenerallyresultfromabreakdowninthecomplexsystemsandprocessesinvolvedinthedeliveryofhealthcare.Inordertopreventhealthcareincidentsandreducetheharmassociatedwithincidents,itisnecessarytoexamineandredesign current systems to focuson the safetyofpatients.Ourhealth careprofessionals need towork insystemsthataredesignedtocatchandmitigatehumanerror.

Underpinningthemovementtoimprovepatientcareisthephilosophythatallofuswhoworkinhealthcaremusttakeresponsibilityforourownbehaviour,andtheactionsofindividualsandteamswhoworkwithus.Clinicalgovernanceisarecentlydevelopedconceptthatbringstogetheralltheactivitiesthatdemonstratetoourpatients,thecommunity,governmentandourpeersthatweholdourselvesresponsibleforprovidingsafe,highqualityhealthcare.

TheDepartmentofHealth(WA)isactivelyworkingtoimprovethesafetyofpatientsandistakingthenecessaryandappropriatemeasurestoreducerisks.AcrossWesternAustralia,manycomponentsofclinicalgovernancearealreadyinplaceandcliniciansandmanagersinourhospitalsandhealthservicesareleadingtheworldintheiruseofclinicalinformationtohelpthemimprovethecaretheyprovide.

Significantprogresshasbeenmade,butcontinuingdevelopmentsinmedicaltechnologyandthedeliveryofhealthcarebringnewchallengestopatientsafety.Ourhospitalsandhealthservicesare,therefore,committedtocontinuallyreviewingandupdatingpracticeinthelightoftestedandevaluatedevidencesopatientscanbeconfidenttheyaregettingmodern,effectiveandsafetreatment.

3. Health care incident reporting, investigation and monitoringAhealthcareincidentisdefinedasaneventorcircumstanceresultingfromhealthcarethatcouldhave,ordid,leadtounintendedand/orunnecessaryharmtoaperson,and/oracomplaint,lossordamage.InordertoimprovethesafetyandqualityofhealthcareprovidedinWesternAustralia,theDepartmentofHealth(WA)

implementedacomprehensive,statewideclinicalriskmanagementprogramthatincorporates:

l incidentreporting;

l incidentinvestigation;and

l incidentmonitoring.

Ourgoalisahealthcareenvironmentthatisasfreeaspossiblefromhealthcareincidents.Thefirststeptoimprovingpatientsafetyistolearnabouttheproblembycollectingincidentdata,inparticular,informationaboutthetypesandfrequencyofincidentsthatareoccurring.Analysisofthedata,throughincidentinvestigationandmonitoring,canhelphospitalsandhealthservicestofindwaysofmakingpatientcaresafer.

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3.1 Incident ReportingIncidentreportingfocusesonthecollectionofhealthcareincidentdata,inparticularinformationaboutthetypesandfrequencyofincidentsthatareoccurring.InordertofacilitateincidentreportingtheDepartmentofHealth(WA)hasputinplaceacomprehensive,statewideincidentreportingprogram.Incidentsthatarereportedtotheprogramareinvestigatedandmanagedsothatstrategiescanbeputinplacetopreventsimilarincidentsfromoccurringinthefuture.Theprogramdoesnotcapturethosehealthcareincidentsinwhichtherewasprofessionalmisconductorcriminalactivityastheseincidentsaredealtwithviaseparatemanagementprocesses.

3.2 Sentinel EventsSentineleventsarerarepreventableeventsthatleadtoorcanleadtoseriouspatientoutcomes.InOctober�003 theDepartmentofHealth (WA) introduced the Sentinel Eventprogram,which requiresall public andprivatelicensedhospitalstoreportsentineleventstotheChiefMedicalOfficerwithinsevenworkingdaysoftheincidentoccurring.

In�00�,AustralianHealthMinistersendorsedasetofeightcoresentineleventcategoriesthatarereportablenationally.WesternAustraliahasendorsedtheseeightcategoriesplusanadditionalcategoryof‘other’adverseeventsothatanyotherrarepreventableeventleadingtounintendedseriouspatientharmordeathcanbecapturedandlearnedfrom.Todate,VictoriaandNSWaretheonlyAustralianjurisdictionstohavepublisheddataonthecoresetofnationalreportablesentinelevents.

HospitalsandhealthservicesinWesternAustraliaarerequiredtoreportthefollowingsentinelevents:

�. Proceduresinvolvingthewrongpatientorbodypart;�. Suicideofapatientinaninpatientunit;3. Retainedinstrumentsorothermaterialaftersurgeryrequiringre-operationorfurthersurgical procedure;�. Intravasculargasembolismresultingindeathorneurologicaldamage;5. HaemolyticbloodtransfusionreactionresultingfromABOincompatibility;6. Medicationerrorleadingtothedeathofapatientreasonablybelievedtobeduetoincorrect administrationofdrugs;7. Maternaldeathorseriousmorbidityassociatedwithlabourordelivery;8. Infantdischargedtowrongfamilyorinfantabduction;and9. Otheradverseeventresultinginseriouspatientharmordeath.

Aspartofsentineleventmanagement,reportingsitesmustassembleamultidisciplinaryteamtoinvestigatesentineleventstoexaminethecircumstancesoftheeventandtoidentifyfactorsthatcontributedtoit.Theinvestigationteammustthendevelopstrategiesthatthereportingsitecanputinplacetoreducetheriskofsimilareventsfromoccurringinthefuture.Itisimportantthatthesestrategiesaremonitoredonaregularbasistoensuretheireffectivenessinimprovingpatientsafety.

InWesternAustralia,thepreferredapproachtohealthcareincidentinvestigationisRootCauseAnalysis,whichisbasedonthemethoddevelopedbytheVeteran’sHealthAdministrationintheUnitedStates.Thisstandardinvestigationapproach is nowused inmostWesternAustralianhospitals (public andprivate) to investigatesentinelevents.

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Tosupporttheinvestigationprocess,theDepartmentofHealth’s(WA)OfficeofSafetyandQualityinHealthCareofferstrainingandsupportintheRootCauseAnalysisinvestigationmethod.SinceAugust�003,over500healthcarestaffacrossthestatehavebeentrainedintheRootCauseAnalysismethodology.Furthertrainingisplannedfor�005/06.Adedicatedteamofclinicalandnon-clinicalstaffisalsoavailabletoassistsiteswithinvestigations.

Giventheclinicalcomplexityofmanysentinelevents,ahighlevelconfidentialSentinelEventReviewGrouphasbeenestablishedtoassessandcommentonthede-identifiedinvestigationfindingsofeventsreportedtotheChiefMedicalOfficer.Wherethegroupbelievesthattheinvestigationofaparticulareventhasidentifiedsystemimprovementsthatarerequiredinsimilarinstitutions,aStatewidePatientSafetyAlertmaybereleased.ThereviewgroupmeetsonaquarterlybasisandconsistsofseniorcliniciansincludingtheChiefMedicalOfficer,theChiefPsychiatrist,theChiefNurseoftheDepartmentofHealthandcliniciansfromteachinghospitals.

4. Sentinel Event ProgramBetween�October�003,whenthesentineleventprogramwasimplemented,and30June�005,70sentineleventshavebeenreportedtotheChiefMedicalOfficer.Oftheseevents,twowereconsideredunpreventableleaving68eventstobeeligibleforinclusionintheprogram.Thisreportfocusesonthesentineleventsreportedforthe�003/0�and�00�/05financialyears(NB:the�003/0�financialyearcomprisesninemonthsofdataonly,ie.fromimplementationoftheprograminOctober�003to30June�00�).

During�003/0�,�3eventswerereportedbutonlyfourofthesefellintothecoresetofnationalreportablesentinel events (Table �). During �00�/05, �5 events were reported of which �0 fell into the core set ofevents.

Table 1: Reported sentinel events for WA public and private hospitals, 1 October 2003 to 30 June 2005

Eventcategory 2003/04* 2004/051. Procedureinvolvingwrongpatientorwrongbodypart 1 �0

2. Suicideofapatientinaninpatientunit 1 �

3. Retained instruments or other material after surgery requiringre-operationorfurthersurgicalprocedure

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4. Medicationerrorresultingindeathofapatient 0 �

5. Intravasculargasembolismresultingindeathorneurologicaldamage

0 0

6. HaemolyticbloodtransfusionreactionresultingfromABOincompatibility

0 0

7. Maternaldeathorseriousmorbidityassociatedwithlabourordelivery

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8. Infantdischargedtowrongfamily 0 0

9. Other �9 �5

Total 23 45

*NB: 2003/04 data comprises nine months only – 1 October 2003 to 30 June 2004.

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Themajorityofsentineleventsreported inWesternAustraliaduringbothfinancialyearswereclassifiedas‘otheradverseeventresultinginseriouspatientharmorpatientdeath’.Table�providesadetailedanalysis

oftheeventsreportedtothe‘other’category.

Table 2: Detailed analysis of the ‘other’ category of sentinel events for WA public and private hospitals, 1 October 2003 to 30 June 2005

5. Contributing system factorsAtthetimeofpublication, investigationfindingsfrom6�reportedsentineleventshadbeenreceived. Theinvestigation teams for the remaining four sentinel events have been granted extensions due to specialcircumstances.Anoverallreviewofthesefindingsidentifiedabroadrangeofsystemfactorsthatcontributedtotheevents.Thesecontributingfactorshavebeencategorisedaccordingtotheclassificationsystemdeveloped

bytheDepartmentofHumanServices,Victoria.Thetencategoriesare:

�. Communication(communicationbetweenstaff,communicationbetweenstaff,patientsandfamily members);

�. Equipment(faultyequipment,lackofequipmentprovision);

3. Externalfactors(issuesexternaltothereportingorganisation);

�. Healthinformation(documentation–orlackof–inmedicalrecord,communicationofinformation betweenhealthserviceandexternalserviceproviders);

5. Humanresources(staffallocation,stafftraining,staffsupervision,staffappraisals,recruitment);

6. Inter-hospitalissues(issueswithtransferofapatientfromonehealthserviceprovidertoanother);

7. Physicalenvironment(issueswiththephysicalenvironmentofthehealthserviceorgeneralsuitability oftheenvironmenttosupportthefunctionitisbeingusedfor);

8. Policy,proceduresandguidelines(behaviouralassessment,physicalassessment,patientobservation process,clinicalmanagementguidelines,identificationprocess,coordinationofcare);

9. Translationissues(issueswithtranslationofhealthinformationforapatient);

Eventcategory 2003/04* 2004/05 TotalComplicationofanaestheticmanagement 0 � �

Complicationofemergency/resuscitationmanagement 4 3 7

Complicationofsurgery(includingpostoperativedeath) 8 8 �6

Foetalcomplicationofdelivery(includingneonataldeath) � 3 5

Hospitalprocessissue(ie.failuretoaccesstimelyandappropriatecare,poorplanningofdischarge)

3 8 ��

Medicationerrorwithseriousconsequence(notdeath) 0 � �

Patientabscondingwithadverseoutcome � 0 �

Other � 0 �

Total 19 25 44

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�0. Transportationissues(issueswithinteragencyorhealthservicetransportationofapatient);and,

��. Otherfactors(patientcomorbidities).

AfulldescriptionofthesecontributingfactorscanbefoundatAppendixOne.

Issueswithpolicies,proceduresandguidelines(e.g.absenceofpolicies,proceduresandguidelinesregardingclinical management or use of inappropriate/unsuitable policies, procedures and guidelines) was the mostcommontypeofcontributingfactorofsentinelevents(Figure�).Othercommoncontributingfactorstosentineleventsreportedduringboth�003/0�and�00�/05included:

n humanresourceissueswhichtypicallyincludedlimitedstaff,inadequaciesinstafftraining,lackof staffsupervision;

n healthinformationissuesincludingfailuretodocumentpatientinformationinthemedicalrecord; and

n communication problems which generally involved lack of communication between junior andseniormedicalstaffandmiscommunication/lackofcommunicationbetweenmedicaland nursingstaff.

Figure 1: Contributing factors of sentinel events, for WA public and private hospitals, 1 October 2003 to 30 June 2005 (n=64)

NB: Total may exceed 100% as one sentinel event can have more than one contributing factor.

0% 10% 20% 30% 40% 50% 60% 70%

Transportation

Translation

Other

Interhospital

Human resources

Health information

External factors

Equipment

Communication

Policy/Proc/Guidelines

Physical environment

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Abreakdownofcontributingsystemfactorsbyeventtypefollows.

5.1 Procedure involving the wrong patient or body partThiscategorycaptureseventsinwhichaprocedure(includingsurgery)wasperformedonthewrongpatientorwrongbodypart.Wrongbodypartalsoincludesthoseeventsinwhichaprocedureorsurgerywasperformed

onthewrongsideofthebody.

Oneeventwas recorded in thiscategory for�003/0�and�0eventswererecordedfor�00�/05. Themostcommontypeofeventwasaprocedureofsurgerybeingperformedonthewrongbodypart(n=8).

Investigation findings were available for �0 sentinel events. Analysis of the findings revealed a range ofcontributingfactors:

n communicationdeficienciesbetweenstaffandpatientandbetweenstaffmembers;

n lackofhealthinformation;

n humanresources(inexperiencedstaffinpositionsatalevelgreaterthantheirexperience);

n policy,procedureorguidelines(lackofcompliance,absenceofrelevantpolicy,procedureor guidelines,inadequatepatient/siteidentificationprocess);and

n other(noisyenvironment,patientfactors).

The reportingorganisationshaveput inplaceanumberof strategies toprevent this typeof incident fromoccurringinthefuture.Theyinclude:

n development and implementation of standardised policies and protocols regarding the identificationofpatients(eg.confirmingpatientidentitypriortoprocedureorsurgery,confirming identificationofcorrectsitepriortoprocedureorsurgery);and

n limitingthenumberofvisitorstotheOperatingTheatretoareasonablelevel.

Inrecognitionthattheseeventsarepreventable,theAustralianCouncilforSafetyandQualityinHealthCarehasrecentlydevelopedafivestepEnsuring Correct Patient, Correct Site, Correct Procedure protocol.

Step 1: Checkingtheconsentformorprocedurerequestformiscorrect;

Step 2:Markingthesiteforthesurgeryorotherinvasiveprocedure;

Step 3:Confirmingidentificationwiththepatient;

Step 4: Takinga‘teamtimeout’intheoperatingtheatre,treatmentorexaminationarea;and

Step 5: Ensuringappropriateandavailablediagnosticimages.

The WA Office of Safety and Quality in Health Care has collaborated with the Royal Australian College ofSurgeonstodevelopastatewideprotocolbasedontheAustralianCouncil’sFiveStepProtocol.ThishasbeendisseminatedtoallhospitalsandhealthservicesviaDepartmentofHealthpolicy.

5.2 Suicide of a patient in an inpatient unitThis category captures suicide that has occurred while the patient is being cared for in a hospital orhealth service. Two events were recorded in this category with one occurring in each financial year.

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Systemfactorsthatappearedtocontributetotheseeventsincluded:

n communication(lackofcommunicationbetweenmedicalandnursingstaff);

n other(patientfactors);

n physicalenvironment(patientaccesstohangingpoints);and

n policies,proceduresandguidelines.

Anumberofstrategies,includingchangestothephysicalenvironmenttoreduceaccesstohangingpoints,havebeenputinplacetoaddressthesystemvulnerabilities.AllWAhealthserviceshavebeenmadeawareofthesestrategies.

5.3 Retained instruments or other material after surgery requiring re-operation or further surgical procedure

Thiscategorycapturesthoseeventsinwhichsurgicalinstrumentsorothermaterialsuchasgauzepacksareinadvertentlyleftinsidethepatientwhenthesurgicalincisionisclosed.

Atotalofseveneventswererecordedinthiscategory.Oneeventwasreportedin�003-0�andsixwerereportedin�00�-05.Investigationfindingswereavailableforallsevenevents.Themajorityofeventsinvolvedretainedmaterials,inparticularsponges,swabsandpacks.

Investigationfindingsfortheseeventsrevealarangeofcontributingfactors,including:

n communication(sub-optimalcommunicationbetweentheatrestaff);

n equipment(nonstandardisedandinsufficientequipment);

n healthinformation(insufficientinformationinmedicalrecordregardingcount);

n humanresources(absenceofstaffcompetenciesregardingsurgicalcounts,relevantpersonnel notpresentatalltimes);

n policy,procedureandguidelines(lackofcomplianceandabsenceofguidelinesregardingcount discrepancies);and

n otherfactors(ie.timepressures,operationmorecomplexthanexpected).

Asaresultoftheinvestigationfindings,reportingorganisationshaveintroducedstrategiestoreducetheriskofinstrumentsorothermaterialbeinginadvertentlyleftinsidethepatientwhenthesurgicalincisionisclosed.Examplesinclude:

n developmentofasurgicalcountskillcompetency;

n developmentofguidelinesregardingactionfollowingtheeventofacountdiscrepancy;

n introductionofmandatoryrunningcountsforproceduresinexcessoftwohours;

n areviewoftheatreschedulingtorelievetimepressures;and

n considerationofoptionsforincreasingequipmentavailability.

TheWAOfficeofSafetyandQualityhasalertedWAhealthservicestotheriskfactorsassociatedwithretainedinstrumentsandmaterialsfollowingsurgeryandadvisedthemofstrategieswhichcanbeusedtopreventthistypeofeventfromoccurringinthefuture.

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5.4 Medication error resulting in deathThiscategoryincludeseventsinwhichthedeathofapatientisreasonablybelievedtobeduetotheincorrectadministration of drugs. This can include the wrong drug being given, wrong dosage, wrong route andinsufficientsurveillance(eg.bloodtests,clinicalobservation).Twoeventswerereportedinthiscategoryandtheinvestigationsrevealedthefollowingcontributingfactors:

n communication(insufficientcommunicationbetweenstaffcaringforpatient);

n healthinformation(lackofdocumentationinmedicalrecord);

n humanresources(stafftraininginadequacies);

n policies,proceduresandguidelines(deficientguidelinesregardingprescriptionwritingandlack ofavailabilityofguidelinesregardingparticulargroupsofdrugs);and

n physicalenvironment(lackoflighting,clutteredworkspace,ambiguoussignage).

Anumberofstrategieshavebeendevelopedandimplementedasaresultoftheseevents.Theyinclude:

n revision and amendment of guidelines regarding prescription writing (eg. time of administrationmustberecorded);

n ensuringadequatenightlightingavailable;

n provisionofanunclutteredworkenvironment;and

n staffeducationregardingmedicationadministration.

5.5 Maternal death or serious morbidity associated with labour or deliveryThiscategorycapturesthoseeventsinwhichtherewasdeathorseriousdisabilityassociatedwithlabourordeliveryinalow-riskpregnancywhilethewomanwasbeingcaredforinahealthservice.Itincludeseventsthatoccurwithin��dayspost-deliveryandexcludesdeathsfrompulmonaryoramnioticfluidembolism,acutefattyliverofpregnancyorcardiomyopathy.

Twoeventswerereportedinthiscategory,withoneeventoccurringineachfinancialyear.Analysisofthefindingsrevealsthefollowingcontributingfactors:

n healthinformation(lackofdocumentationinmedicalrecord);

n humanresources(medicalandnursingtraininginadequacies,lackofsystemtomonitor trainingadequacyovertime,absenceofprogramtoidentifywhattrainingisneeded);and

n policies,proceduresandguidelines(absenceofguidelinesregardingbehaviouralassessment andclinicalmanagement).

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Strategiesthathavebeenintroducedinclude:

n staff education programs that include mock obstetric emergencies and identification of postnataldistress;and

n areviewofmaternaldocumentationtoensuretimelyvisualisationoftrendsinmaternalvital signs.

5.6 Other adverse event resulting in serious patient harm or death5.6.1 Complication of anaesthetic managementTheadministrationof anaesthetic agents carries somedegreeof risk. This sub-category includesall thoseevents inwhich thepatient sufferedproblemsor complications followingadministrationofananaesthetic.Onlyoneeventofthistypewasreported.Analysisoftheinvestigationfindingsshowedthat lackofhealthinformationwasacontributingfactor.Thereportingorganisationhasimplementedguidelinesregardingthepatientobservationprocessandhowthisinformationshouldbedocumentedinthepatient’smedicalrecord.

5.6.2 Complication of emergency / resuscitation managementThissub-categorycapturesthoseeventsinwhichstaffexperiencedproblemsinmanaginganemergencysituation(forexample,aheartattackorhemorrhaging)orresuscitatingthepatient.Seveneventswerereportedinthiscategory,withfouroccurringin�003/0�andthreeoccurringin�00�/05.

Commonunderlyingsystemfactorsincluded:

n communication(absenceofclearteamcommunicationprocesses);

n equipment(failureandlackofmaintenance);

n healthinformation(fragmenteddocumentation);

n humanresources(absenceofsystemtomonitorstaffcompetencyinresuscitation);

n physicalenvironment(reducedvisibilityofemergencybutton);and

n policies,proceduresandguidelines(absenceofemergencyresponsepolicies,proceduresand guidelines).

Strategiesdevelopedandputinplacebyreportingorganisationsincluded:

n developmentofaprogramtoenhancecommunicationandteamworkinemergencysituations;

n developmentofstandardsforemergencyresponseincludingteamleadership,teamprocesses andskillmaintenance;

n staffeducationandtrainingtoensurecompetenceinneonatal,paediatricandadult resuscitation;

n developmentofstandardsforemergencyequipmentcheckingincludingdefibrillatorand resuscitationequipmentandroomsetup;

n developmentofstandardsforprocurementandimplementationforemergencyequipment;

n usinggreentubingforoxygenandredtubingforair;

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n removingairflowmetersfromwallwhennotinuse;and

n placingclearperspexaroundemergencybuttons.

5.6.3 Complication of surgery (including post operative death)Allsurgery(includingprocedures)carriessomedegreeofrisk.Eventsinthissub-categoryincludeanycomplicationsduringorimmediatelyaftersurgerythatarepoorlymanagedresultinginseriousmorbidity(disease)ordeath.Examples include perforation of internal organ(s) resulting in septicaemia (blood poisoning) and failure todiagnoseandtreatpulmonaryembolus(blockageofanarteryinthelungsbyfat,airorabloodclot).

Sixteeneventsofthistypehavebeenreportedtothesentineleventprogram,witheightoccurring ineachfinancialyear.Atthetimeofpublicationinvestigationfindingswereavailableforthirteenoftheseevents.Underlyingsystemfactorsincluded:

n communication(lackofcommunicationbetweenstaffandbetweenstaffandpatientand familymembers);

n equipment(preferredinstrumentsnotavailable);

n healthinformation(lackofdocumentationinmedicalrecord);

n humanresources(staffallocation,stafftraining,staffsupervision);

n policies,procedures,guidelines(deficientpoliciesregardingpatientobservationprocess, absenceofclinicalmanagementguidelines);and

n other(patientfactors).

Strategiesintroducedtoremedythesesystemvulnerabilitiesincluded:

n developmentofpoliciestoaddressmedicaltraininginadequaciesinclinicalproceduresand supervisionrequirementsforjuniorstaff;

n development of a process to ensure relevant health information is communicated to all relevantstaff(withinandexternaltothehospital)caringforthepatientinatimelymanner;

n developmentofpolicies,proceduresandguidelinesregardingpre-operativeassessmentof patients(includingriskassessmentforsurgicalthromboemboliandprophylacticinterventions), clinicalmanagement(e.g.chestdraininsertion)andco-ordinationofcare;and

n improvementofdocumentationinthepatient’smedicalrecord.

5.6.4 Foetal complication of delivery (including neonatal death)Itiswidelyacknowledgedthatcomplicationsduringlabouranddeliverycanoccur.Sentineleventsthatfallintothissub-categoryhoweverincludethoseeventsinwhichcomplicationswerenotanticipated,andwerenotmanagedinatimelyorappropriatemannerplacingthebabyatriskofinjuryordeath.Fiveeventsinthissub-categorywerereported,withtwooccurringin�003/0�andthreereportedin�00�/05.

Systemfactorscontributingtotheseincidentsincluded:

n lackofcommunication(betweenstaff,betweenstaffandpatientandfamilymembers);

n healthinformation(sub-optimalcommunicationofhealthinformationbetweenthehealth serviceandexternalserviceproviders,lackofdocumentationinthemedicalrecord);

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n humanresources(stafftraininginadequacies,absenceofsystemtomonitorstaffcompetency, lackofstaffsupervision);

n policies,proceduresandguidelines(inadequatepolicyregardingpatientobservationand

clinicalmanagement);and

n other(patientfactors,complicateddelivery).

Strategiesintroducedasaresultofincidentinvestigationsincluded:

n staffeducationandtrainingtoensuremaintenanceofcompetencyincardiotocograph(CTG) interpretation,careofthesickneonateincludingintensivecaremanagement,neonate resuscitationandneonatepreparationbeforelongdistancetransfer;

n developmentofpolicies,proceduresandguidelinesregardingphysicalassessmentofpatients, patientobservationprocess,co-ordinationofcareandclinicalmanagement(eg.clinical managementoffoetaldistress,managementofpatientswithaprevioushistoryofcomplicated deliverywithneonatalcompromise);

n development of a system to ensure complete documentation of physical assessment and patientobservationinthepatient’smedicalrecord;

n developmentofaprocesstoimprovecommunicationofpatienthealthinformationbetweenthe hospitalandexternalhealthserviceproviders;and,

n introductionofapatienthandheldmaternityrecordsystem.

5.6.5 Hospital process issuesThissub-categorycapturedthoseevents inwhichhospitalprocessessuchastriaging, initialassessmentandcommencementoftreatmentcontributedtoseriouspatientmorbidityordeath.Threeeventsofthistypewerereportedin�003/0�andeighteventswerereportedin�00�/05.Analysisofinvestigationfindingsidentifieda

rangeofsystemfactorsthatcontributedtotheseincidents:

n communication(betweenstaff,betweenstaffandexternalserviceproviders,betweenstaffand patientandfamilymembers);

n equipment(faultyequipment,equipmentdesignnotenablingstafftodetect lifethreatening problems);

n healthinformation(lackofand/orincorrectdocumentationinmedicalrecord,staffdifficulty inaccessingpatientresultsafterhours);

n humanresources(staffshortage,inexperiencedstaffinpositionsatalevelgreaterthantheir experience,inadequatestaffsupervision);

n interhospitalissues(lackofcommunicationofhealthinformationbetweenserviceproviders);

n policies,proceduresandguidelines(lackoforinadequatepoliciesregardingpatientobservation processandco-ordinationofcare,lackoforinadequateclinicalmanagementguidelines);

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n physicalenvironment(lackofappropriateholdingareaforpsychiatricpatients);and,

n transportation(inadequatereferralprocesses,co-ordinationofretrievalservicesbetweenhealth services)

Strategieshavebeenimplementedtoaddressthesesystemvulnerabilities.Theyinclude:

n developmentofpolicies,proceduresandguidelinesregardingphysicalandbehaviouralassessment ofpatients,patientconsent,patientobservationprocess,co-ordinationofcareandclinical management (eg. clinical pathway for patients presenting to the Emergency Department, clinicalpathwayformanagementofuppergastrointestinalmalignancy);

n developmentofaprocesstoensureappropriatereferraloftransferpatients;

n staffeducationregardingclinicaldocumentationrequirements;

n reviewofequipment;and

n communicationwithmanufacturersofequipmentadvisingthatcurrentequipmentdesigndoes notenablestafftodetectlifethreateningproblems.

5.6.6 Medication error resulting in serious consequence (not death)This sub-category includes those events in which administration of medication has resulted in seriousconsequencesbutnotdeath.Examplesincludeirreversibletoxicity(eg.ototoxicity),cardiacarrestasaresultofoverdoseorseriousadversereactionsresultingfromadministrationofpenicillintopatientswithaknown

penicillinallergy.

Twoeventsofthistypewerereportedwithbothoccurringin�00�-05.Analysisoftheinvestigationfindingsrevealedthefollowingfactorscontributedtotheevents:

n communication(lackofcommunicationbetweenstaffandbetweenstaffandpatient);

n healthinformation(lackofinformationinmedicalrecord);

n humanresources(inexperiencedstaff);and

n policy,procedureandguidelines(absenceofpolicyforassessingpatientrisks).

Examplesofstrategiesdevelopedandimplementedtoreducethesetypesofeventsinclude:

n revisionofpatientassessmentpoliciestoincorporateprocessesforassessinganddocumenting patientrisks;and

n staffeducationregardingidentificationandmanagementofallergicreactions.

5.6.7 Patient absconding with adverse outcomeThissub-categorycapturesanypatientdeathorseriousdisabilityassociatedwithpatientdisappearanceformore than four hours. One event of this type was reported during �003/0�. The investigation identified

followingcontributingsystemfactors:

n communication(betweenstaff,betweenstaffandpatient);and

n policies,proceduresandguidelines(inadequatepolicyregardingbehaviouralandphysical assessment,failuretocomplywithpolicy).

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Strategiesintroducedtoremedythesesystemvulnerabilitiesincluderevisionandamendmenttobehavioural

andphysicalassessmentpolicy.

5.6.8 Other sentinel eventsEvents inthissub-category includeanyeventsthatcomeunderthesentineleventdefinitionbutcannotbeclassifiedintoanyofthelistedcategories.Sucheventscouldincludepatientdeathorseriousdisabilityduetospinalmanipulation,patientdeathorseriousdisabilityassociatedwithaburnincurredfromanysourceorpatientdeathassociatedwithafallwhilebeingcaredforinahospitalorhealthservice.

One event in this sub category was reported. The investigation identified the physical environment as acontributingsystemfactorandasaresult,thereportingorganisationhasputinplaceanumberofstrategiestomodifythephysicalenvironmentinordertopreventthistypeofincidentfromoccurringinthefuture.

6. The year aheadThis is the firstpublic reportpublishedby theDepartmentofHealth (WA)on thestatewidesentineleventprogram.Assentineleventsaredistressingforallinvolved,theDepartmentofHealth(WA)andhealthservicesareworkinghardtoimproveoursystemsandprocessessothattheseeventsaremuchlesslikelytohappenagaininthefuture.

TheWAOfficeofSafetyandQuality inHealthCarecontinuallyanalysesthesentineleventdatato identifyemergingtrendsandpatterns,includingactualandpotentialrisks.TheyprovidethisinformationtohospitalsandhealthservicesacrosstheStatethroughanumberofchannelsincluding:

n aquarterlynewsletterforsentinelevents;

n statewidealertsforsignificantevents;

n aquarterlynewsletterforhealthcareincidents,Sharing News in Patient Safety (SNIPtS);

n quarterlyreportsandspecialfocusreportsonstatewidehealthcareincidentdata;and

n theAnnualPatientSafetySeminar.

Most importantly, these publications and the annual seminar highlight some of the innovative measuresimplementedinhospitalsandhealthservicesthatareresultingintangibleimprovementstopatientcare.Byprovidingthisinformation,hospitalandhealthservicestaffareencouragedtoreviewtheirownhealthcareincidentdatatoidentifypotentialrisksandtakepreventiveactiontostrengthentheirsystemsandsignificantlyreducetheriskofsuchincidentsoccurring.

Itisvitalthathospitalsandhealthservicescontinuetheirworktowardsmakingpatientsafetyanintegralpartinthedeliveryofhealthcare.TheDepartmentofHealth(WA)willcontinuetosupporthospitalsandhealth

servicestoimprovepatientcarein�005/06throughthefollowingactivities:

n furthertrainingintheRootCauseAnalysismethodology;

n participationinthenationalOpenDisclosurepilot;

n notificationofsystemwideissuesthatrequireurgentattention;

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n developmentofaClinician’sToolkitforimprovingpatientcare;and

n transferringknowledgeessentialtoimprovingpatientsafetyandquality.

7. What can consumers do?Bytakinganactiveroleintheirhealthcare,andbeingpartofthe‘team’,consumerscanhelpmakesuretheygetthebestpossiblecarefortheirneeds. Toencouragepeopletobecomemoreactively involvedintheirhealthcaretheAustralianCouncilforSafetyandQualityinHealthCarerecentlyproducedtheTen Tips for Safer Health Care booklet.Thisbookletexplainshowandwhythingscangowrongandhowapersoncanworkinpartnershipwiththeirhealthcareprofessionalstogetthebestpossiblecare.Thebookletalso:

n gives ten tips for improvinghealth care,which includequestions apersonmight like to ask theirhealthcareprofessional;

n outlineswhatapersoncanexpectfromtheirhealthcareprofessional;

n listssomesourcesofinformationforfindingoutmoreaboutaparticularconditionandhowto managemedicines;and

n explainswhatapersoncandoiftheyhaveconcernsabouttheirhealthcare.

ThesebookletshavebeendistributedtoeveryWesternAustralianhospitalandhealthservice.

8. Contact informationFor more information, consumers can contact their local hospital patient liaison officers or complaintco-ordinators.

Consumersmayalsowishtocontactthefollowingagencies:

Health Consumers Council of Western Australia

http://www.hcc-wa.asn.au

Telephone:(08)9���3���

Freecall:�8006�0780

Email:info@hconc.org.au

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Office of Health Review

http://www.healthreview.wa.gov.au

Telephone:(08)93�30600

Freecall:�8008�3583

Department of Health (WA) - Office of Safety and Quality in Health Care

http://www.health.wa.gov.au/safetyandquality/

Telephone:(08)9����080

Email:safetyandquality@health.wa.gov.au

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APPENDIX ONEContributingfactordescriptions

TheDepartment ofHuman Services (Victoria) developed the contributing factors framework that has beenusedbytheDepartmentofHealth(WA)whenanalysingsentinelevents.TheDepartmentofHumanServices(Victoria)haskindlygivenpermissionforthecontributingfactordescriptionstobereproducedinfullinthisdocument.

Eachrootcauseanalysisidentifiesthecontributingsystemsfactorsthatimpactedontheevents’occurrence.ThefactorsidentifiedintheeventsreportedinVictoriafor�00�-03werereviewedandaclassificationsystemwasdeveloped.ThesystemisadaptedfromtheJointCommissiononAccreditationofHealthCareOrganisations’reportingrootcauseanalysistemplateandfromtheNewSouthWalesHealthInstituteforClinicalExcellence’sChecklist flip chart for root cause analysis.�

Thecontributingfactorsthatareincludedineachofthecategoriesareoutlinedbelow.

Procedures and guidelinesThiscategoryincludesallcontributingfactorsthatarearesultofaprocedure,policyorguideline.Theseareissues relating to the existence and ready accessibility of policy or guidelines,misunderstanding ormisuseofcurrentproceduresandguidelines,or failuretocomplywithcurrentprocedure. Acommonsubcategorythatimpactsonthiscategoryinvolvestheorientationandtrainingofstaffandavailabilityofinformationandtrainingforpolicyandguidelinecomplianceforparttime,temporary,orvoluntaryworkersandstudents.Sub-

categoriesinclude:

Behavioural assessment

This sub-category involves any policy or procedure or guidelines surrounding the processes involved in theassessmentofapatient’sbehaviour.Thiscategoryisofmostrelevancewhenestablishingapatient’ssuicidalorself-harmintent.Thiscategoryisalsorelevantfortheprocessesinvolvedinestablishingapatient’scognitivestate, particularly whether the patient is at risk of wandering, absconding or causing harm to staff. This

contributingfactorimpactspredominantlyonthesentineleventsof‘suicideasaninpatient’.

Physical assessment

This sub-category involvespolicyorprocedureorguidelines surrounding technical information forassessingpatient risks, mechanisms for feedback on key processes and effective interventions development after

events.

Patient observation process

Thesub-categoryinvolvesanypolicyorprocedureorguidelinessurroundingtheprocessesinvolvedintheclinicalobservationofapatient.Thiscategorymightincludeeithermedical,nursingoralliedhealthproceduresfor

guidelines.Examplesoffactorsthatmightbeincludedinthissub-categoryare:

n policiesinvolvingoperativeorpost-operativeclinicalobservation

1 New South Wales Department of Health 2203, Checklist flip chart for root cause analysis teams, Sydney.

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n policiesorproceduresinvolvingneurologicalobservationspost-headinjury

n policiesorproceduresinvolvingobservationofpatientsatriskofself-harmorabsconding.

Clinical management guidelines

This sub-category involves any policy or procedure or guidelines surrounding the processes involved in theclinicalmanagementofpatients.Itmightincludeeithermedical,nursingoralliedhealthclinicalmanagementplans.Examplesofclinicalmanagementguidelinesare:

n clinicalpathwaysonthemanagementofstrokepatients

n clinicalpathwaysonthepre-operativemanagementofpatientsforbowelsurgery

n clinicalmanagementguidelinesonthemanagementofpatientspost-myocardialinfarction

n lackofexistenceofpolicyandguidelinesornoncompliancewithexistingpolicyandguidelines.

Identification process

This sub-category involves any policy or procedure or guidelines surrounding the processes involved in theidentification of patients. This also includes any processes involved in identifying the correct site/side forsurgery/radiologyandsoon.Examplesofidentificationprocessare:

n policiesinvolvingconfirmingapatient’sidentitypriortoanoperation

n policiesinvolvingidentificationofthecorrectsidepriortosurgery(forexample,confirmingthat thekneereplacementwilloccurontheright,notontheleft)

n policiesinvolvingidentificationofthecorrectpatientandsiteforradiotherapy.

Coordination of care

This sub-category involves any policy or procedure or guidelines surrounding the processes required forcoordinating a patient’s care, which are not specifically outlined in the above categories. The processesinvolvedincoordinatingpatientcarecanoverlapbetweendepartments,inpatientandoutpatientdepartments,clinical and non-clinical units, administrative units and external organisations (for example, rehabilitationorganisations,generalpractitioners,RoyalDistrictNursingServiceandsoon).Examplesofprocessesinvolvedinthecoordinationofpatientcareare:

n proceduretoensureoutpatientfollow-upondischarge

n procedurestoensurecommunicationoftestresults

n healthservices’policiesoninfectioncontrol

n operating theatre procedures to ensure pathology specimens obtained in theatre are transportedtothepathologydepartment.

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Transportation issuesThiscategoryincludesallcontributingfactorsthatarearesultofanissuewithinteragencyorhealthservicetransportationofapatient.Suchissuesmightrelateto:

n coordinationofretrievalservicesbetweenhealthservices

n referralprocesses

n provisionofclinicalescortservices.

Translation IssuesThiscategoryincludesallcontributingfactorsthatarearesultofanissuewithtranslationofhealthinformationforapatient.Suchissuesmightinclude:

n notusingtranslationservicesfornon-Englishspeakingpatients

n usingfamilyorcarersfortranslationratherthanprofessionaltranslationservices.

Interhospital issuesThiscategoryincludesallcontributingfactorsthatarearesultofanissuewiththetransferofapatientfromonehealthserviceprovidertoanotherhealthserviceprovider.Suchissuesmightrelateto:

n communicationofhealthinformationbetweenthehealthserviceandexternalorganisationsor otherhealthservice

n provisionofallrelevantdocumentationatthetimeoftransfer

n completionofrelevantinformationatthetimeoftransfer.

Human resourcesThiscategoryincludesallcontributingfactorsthatarearesultofahumanresourceorstaffingissue,includingknowledge,skillsandcompetence.Sub-categoriesinclude:

Staff allocation

Staffallocationmight influencethestressand fatigueof staff thatcanresult fromchange, schedulingandstaffingissuesandsleepdeprivation.Thissub-categoryincludesallissuessurroundingtheallocationofstaff,whethermedical,nursingoralliedhealth.Predominantlytheissuesinvolve:

n medicalunderstaffingandworkloadallocation

n nursingunderstaffingandworkloadallocation

n replacement(orlackof)formedicalandnursingstaffonsickleave

n replacementofstaffonleavewithstaffofaleveltoojuniorfortheposition

n sufficiencyofstaffon-handfortheworkloadatthetime.

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Staff training

Stafftrainingincludesissuesrelatingtoroutinejobtraining,specialtrainingandcontinuingeducation,includingthetimingoftraining.Trainingissuesmightconcerntheapplicationofapprovedprocedure,correctuseofequipmentorappropriatesafetymechanisms.Thissub-categoryincludesallissuessurroundingstafftrainingandexperience,whethermedical,nursingoralliedhealth.Predominantlytheissuesinvolve:

n medicalandnursingtraininginadequaciesinclinicalprocedures

n inexperiencedstaffinpositionsatalevelgreaterthantheirexperience

n trainingundertakenafterthecommencementofnewworkprocesses

n monitoringoftrainingadequacyovertime

n existenceofprogramstoidentifywhattrainingwasactuallyneeded.

Staff supervision

Thissub-categoryincludesall issuessurroundingstaffsupervision,whethermedical,nursingoralliedhealthstaff.Italsocoversarangeoflevelsofexperiencesandpredominantlytheissuesinvolvealackofsupervisionorunder-supervision.Examplesofthecontributingfactorsare:

n thesupervisionrequirementsofjuniormedicalinterns

n thesupervisionrequirementsofnewnursinggraduates

n thesupervisionrequiredfornewlygraduatedsurgicalfellowsinoperatingtheatres

n thesupervisionrequiredforclinicalnursespecialistsinintensivecare.

Staff appraisals

Thissub-categoryincludesallissuessurroundingstaffappraisalsofperformance,whethermedical,nursingoralliedhealthstaff.Theissuespredominantlyinvolvealackofappraisalorlessappraisalthanthatexpectedbytheprofessioninvolved.

Recruitment

Thissub-categoryincludesanyissueaboutmedical,nursingoralliedhealthrecruitment.

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CommunicationCommunicationinvolvestheflowofinformationandavailabilityofinformationasneeded.Communicationisimportantforensuringthecorrectuseofequipmentandtheapplicationofpolicyandprocedures.Thiscategoryincludesallcontributingfactorsthatarearesultofacommunicationissue.Sub-categoriesinclude:

Communication between staff

Thissub-categoryinvolvesallissuesthatarisefrommiscommunicationorlackofcommunication,whichoccursbetweenstaffmembers.Examplesofsuchissuesare:

n lackofcommunicationbetweenjuniorandseniormedicalstaff

n miscommunicationorlackofcommunicationbetweenmedicalandnursingstaff

n miscommunicationorlackofcommunicationbetweendepartmentswithinthehealthservice

n miscommunicationorlackofcommunicationbetweenhealthservicesandexternal organisations.

Communication between staff and patients and family members

Thissub-categoryinvolvesallissuesthatarisefrommiscommunicationorlackofcommunication,whichoccursbetweenstaffmembersandpatientsandfamilies.Suchissuesmightinvolveculturalorlanguagebarriersor‘medicalortechnicallanguage’barriers.Examplesofsuchissuesare:

n astaffmemberexplainingaprocedureinamannerthepatientcouldnotcomprehend

n failuretocommunicatetheresultsofatesttoapatientandfamilymember

n explanationstofamilymembersaboutthemedicalstateofapatient.

Health InformationThiscategoryincludesallcontributingfactorsthatarearesultofanissuewiththehealthinformationofapatient.Suchissuesmightrelateto:

n documentation(orlackof)inthemedicalrecords

n communicationofelectronichealthinformation

n communicationofhealthinformationbetweenthehealthserviceandexternalorganisations.

EquipmentThiscategoryincludesallcontributingfactorsthatarearesultofanissuewithequipment.Predominantly,theissuesinvolvefaultyequipmentorlackofequipmentprovisionandincorrectuseforagivenpurpose,butmightalsorelatetotheuseandlocationofequipment,fireprotectionanddisasterdrillsandcodes.Oftenwhatappearstobeequipmentfailuremightrelatetohumanfactors,policyandprocedurequestions,andtrainingneeds.Examplesare:

n theequipmentdesignnotenablingtheoperatortodetectproblemsorallowingtheoperatorto makeusagemistakes

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n equipmentdisplaysandcontrolsnotworkingproperly

n equipmentinusenotmeetingstandards,specificationsorregulations

n lackofmaintenanceprogramstomaintainequipmentanddocumentationofprevious inspections

n insufficientequipmenttoperformworkprocesses

n noemergencyprovisionsandback-upsystemsincaseofequipmentfailure.

Physical environmentThiscategoryincludesallcontributingfactorsthatarearesultofanissuewiththephysicalenvironmentofthehealthserviceorthegeneralsuitabilityoftheenvironmenttosupportthefunctionitisbeingusedfor,includingenvironmentaldistractions,suchasnoise.Examplesofsuchissuesinclude:

n existenceofenvironmentalriskassessmentprograms

n designofsecuritysystemsinthehealthservicetopreventat-riskpatientsfromabsconding

n designofseclusionroomsforpsychiatricpatientstoavoidself-harm

n designofroomstoallowobservationofat-riskpatients

n designofoutdoorareasforambulantpatientstopreventat-riskpatientsfromfalls.

External factorsThis category includes all contributing factors that are a result of an issue external to the organisations.Examplesofsuchissuesare:

n serviceprovisionfromtheAustralianRedCrossBloodService

n serviceprovisionfromdiagnosticservicessourcedexternally

n lack of availability of beds at an external organisation for an at-risk psychiatric patient, requiringthepatienttobecaredforinahealthservicenotdesignedforsuchpatients.

Other factorsThiscategory includescontributingfactorsthatarisefromissuesotherthanthosediscussedinthissection.An example of such factors is the impact from a busy or stressful environment or patient factors (eg. comorbidities).

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