Leaders Meeting Sentinel event Annual report 2016-17 Overview - PowerPoint PPT Presentation

Quarterly Quality & Safety Leaders Meeting Sentinel event Annual report 2016-17

Overview Update re Incident Response Team Summary of Sentinel Event data 2013-2017 Overview of Sentinel Event data 2016/17 Ambitions for 2018+ Sentinel Event Program - Changes so far

Incident Response Team: Consumers as Partners Branch Director, Consumers as Partners LOUISE MCKINLAY Executive Assistant (shared) Bess Joseph Senior Project Officer Complaints KIM GRATJIOS BANNWART Manager, Incident Response Manager, Consumer Partnerships Manager, Patient Experience and Outcomes NATHAN FARROW LIDIA HORVAT Project Officer Complaints Senior Project Officer LISA FORD Consumer Rep Sentinel Event Senior Policy Officer Senior Project Officer BELINDA MACLEOD Coordinator TBC SMITH MEAGAN WARD JOANNE MILLER Senior Project Officer Senior Project Officer Complaints Academy Lead ANDREA CALWELL Policy Support Role MIRANDA Policy Officer (T/L) Senior Policy Officer CORNELISSON JOANNA WILLIAMS KYLIE FOLTIN AMELIA DE BIE Senior Project Officer Training Lead Rebecca Cooney GRIP PhD Student Senior Policy Officer NADIA CHAVES HELEN SMALLWOOD Senior Project Officer Academy Support TBC GRIP PhD Student EUNICE WONG Graduate BRIANA MASCARO Project Support Officer TBC Graduate KAREN HILL

2013-2017 Overall SE notifications 50 45 40 35 30 No of SE 2013 – 14 25 2014 – 15 2015 – 16 2016-17 20 15 10 5 0 Wrong patient or Suicide in an Retained instrument Intravascular gas Haemolytic blood Medication error Maternal death Infant discharged to Other catastrophic: body part inpatient unit or other material embolism transfusion reaction wrong family ISR 1

2013-2017 Overall SE notifications 50 45 40 35 30 No of SE 2013 – 14 25 2014 – 15 2015 – 16 2016-17 20 15 10 5 0 Wrong patient or Suicide in an Retained instrument Intravascular gas Haemolytic blood Medication error Maternal death Infant discharged to Other catastrophic: body part inpatient unit or other material embolism transfusion reaction wrong family ISR 1

9 - Other categories • Clinical Process/procedure i.e. diagnosis/assessment, procedure/treatment/intervention, tests/investigations, Specimens/results • Behaviour i.e. suicide • Falls resulting in death • Clinical Administration i.e. waitlist delay, interhospital TF delay, delay to US, delay to referral • Medication/IV fluids resulting in harm • Nutrition i.e. choking • Documentation i.e. Incorrect labelling • Health care acquired infection • Medical device/equipment • Patient accident's i.e. entrapment • Resources/org management • Deteriorating Patient – Recognition, escalation and response

9 Other - 2016-17 14 12 10 8 6 4 2 0

Severity of Harm No Permanent Harm 15% Permanent Harm 10% Death 75%

RCA report submission RCA reports submitted in 60 days = 41% Sentinel Event RCA Report Submission times 8 months overdue 1 7 months overdue 1 5 months overdue 2 4 months overdue 1 3 months overdue 6 2 months overdue 10 1 month overdue 9 2 weeks overdue 12 On time (60 days) 30 0 5 10 15 20 25 30 35 Number submitted

Metropolitin Hopsitals - Rate bed days (per 100,000 bed days) Rate bed days (per 100,000 bed days) Q P M N H E K J G F D C A 0.00 0.50 1.00 1.50 2.00 2.50 3.00

Risk Reduction Action Plans - RRAP 2 RRAP where submitted in 2016-17. Less than 3%

Falls 13 patients were reported to have a fall resulting in serious injury (or death) 12 patients died post a fall while in care with 1 patient sustaining a serious cervical spine fracture Age Location 80-87 (n=8) Within Hospital = 6 65-68 (n=2) Mental Health Aged Care = 3 20-30 (n=1) Residential Aged Care = 3 2 of the patients ages were unknown HITH = 1

Falls - Recommendations 42 recommendations (1 report nil recommendations) Category Themes Procedure = 12 Admission Clerking Escalation * Risk assessment Risk Assessment = 9 Delirium, Dementia Bed allocation, roll out tool Review post fall Design of tool Education = 6 Risk assessment Dementia Communication = 4 Handover Equipment = 3 Falls alarms Call bells * Shoe bank

Clinical process / Procedure 12 patients were reported to have had a catastrophic events associated with a clinical process/procedure. Sub theme No. Examples Not performed when indicated, was 8 Oesophageal intubation (2), complications incomplete or inadequate, involved the during or following surgical procedures (6) wrong body part (side or site) or the incorrect process, procedure or treatment. Involved a diagnosis or assessment that 4 Death post discharge from a health service (3), was not performed when indicated or was incomplete assessment of a life threatening incomplete of inadequate. rhythm (1)

Clinical process / Procedure - Recommendations 35 recommendations (1 report nil recommendations) Category Themes Procedure = 7 Revision and update of procedures Education = 7 Of procedures Communication Simulation Communication = 5 Closed loop communication Tools to assist handover Escalation of concern Equipment = 4 * Forced Function

Behaviour 8 Patients who committed suicide were reported in the 9 – the category (combine with the category 2 with equates to 15 patients in total) Patient Status Number Mode Number Patient absconded from an ED 1 Hanging 2 Jumping in front of train 3 Patient on ground leave within a mental health 4 facility Jump from height 3 Patients were on leave from a mental health facility 3 Overdose 2 Patients absconded from a hospital ward 2 Suffocation 1 Within a patient rom (Hospital ward) 4 Jumping in front of car/truck 1 Within a client room (Mental Health facility) 1 MVA 1 Unknown 2

Behaviour - Recommendations 54 recommendations (1 report nil recommendations) Category Themes Risk Assessment = 11 Education = 11 Observation frequency Mandatory training Client / Carer Communication = 10 End of life care Family meetings * Log book Cross agency Procedure = 7 Clinical escalation Safe environment Client search Environment = 5 Fixtures & fittings * Dangerous & inappropriate items

Ambitions for SE program 1. Health services report all sentinel events to SCV. 2. Health services report sentinel events within three days of the incident. 3. All reviews commence as soon as practicable and resources are allocated to ensure timely submission of the review report. 4. All review teams include an independent external panel member. 5. All review teams include a consumer representative. 6. Each review report includes at least one finding and one strong recommendation. 7. RRAP feedback reports are submitted three months after the RCA report was submitted 8. SCV and health services share the learnings and improvements from sentinel events

Changes in 2017-18 year Development of SE process • Change of duration for RCA report (from 60 to 30 working days) • Forms and template updated • Request for extension • Quality assurance • Internal review • Request for withdrawal SE database development with VAHI RCA training now ’in house’ Support throughout the review process / review of draft reports

Sentinel events 2016-17 & 2017-18 18 16 14 12 10 No of SE 8 6 4 2 0 July August September October November December January February March April May June 2016-17 3 6 6 4 6 16 4 9 7 3 4 6 2017-18 5 15 4 11 14 10 6 8

Incident Response Team. Nathan Farrow Joanne Miller Manager, Incident Response Team Senior Project Officer, Incident Response Team T 03 9096 5426 T 03 9096 5426 M 0409 552 986 M 0409 552 986 E nathan.farrow@safercare.vic.gov.au E Joanne.miller@safercare.vic.gov.au Miranda Cornelissen Rebecca Cooney Senior Project Officer, Incident Response Team Senior Project Officer, Incident Response Team T 03 9096 7330 T 03 9096 7330 E miranda.cornelissen@safercare.vic.gov.au E rebecca.cooney@safercare.vic.gov.au