Embed Size (px)
Citation preview
Consumers and the Community
South Australian Patient Safety Report for
2017
page 1 South Australian Patient Safety Report for Consumers and the Community 2017
Standard 2 Partnering with Consumers
Standard 1 Governance for Safety and Quality
in health service organisations
Standard 3 Healthcare Associated Infections
Standard 10 Preventing
Falls and Harm from Falls
Standard 5 Patient Identification and Procedure Matching
Standard 8 Preventing
and Managing Pressure Injuries
Standard 6 Clinical Handover
Standard 7 Blood and
Blood Products
Standard 4 Medication Safety
Standard 9 Recognising
and Responding to Clinical
Deterioration in Acute Health
Care
National Safety and Quality Health Service Standards
The Australian Commission on Safety and Quality Health Care developed ten (10) national standards to improve the quality of health care in Australia. They provide an Australia-wide standard for what we can expect from our health service.
Our health services are assessed against these standards, and the work undertaken to address a number of the standards have been included in this summary report.
‘Preventing and responding to challenging behaviour’ is an additional section covered in this report.
page 2South Australian Patient Safety Report for Consumers and the Community 2017
Keeping every single patient as safe as they possibly can be.
This is the ongoing commitment of SA Health.
As part of that commitment, we produce each year a comprehensive Patient Safety Report which outlines key strategies to improve the safety and quality of our health care system.
As well as highlighting key achievements, this Report also details ‘incidents and near misses’. The reason for this is to help prevent similar events occurring in the future.
You can read the highly detailed Report in full at www.sahealth.sa.gov.au/safetyandquality
Alternatively, you can continue reading here for a much shorter and ‘at a glance’ summary of patient safety in South Australia’s public health system.
SA Health works to create and maintain good quality health services that focus on patients, and is guided by research and safety. This is accomplished by ensuring that:
> patients can get care when they need it
> health care staff respect and respond to patient choices, needs and values
> partnerships are formed between patients, their family, carers and health care providers
> up to date knowledge and evidence is used to guide decisions about care
> safety and quality is collected, analysed and fed back for improvement
> action is taken to improve patients’ experience
> safety is made a central feature of how health care facilities are run, how staff work and how funding is organised.
Introduction
page 3 South Australian Patient Safety Report for Consumers and the Community 2017
Safety and Quality Programs
SA Health Safety and Quality 2017-19 work plan developed with 5 priority areas
> Priority Area 1 Patient safety
> Priority Area 2 Partnering with patients, consumers and community
> Priority Area 3 Quality cost and value
> Priority Area 4 Supporting health professionals to provide safe and high quality care
> Priority Area 5 Safety Learning System (SLS)
> Priority Area 6 Communication strategy to support safety and quality
Graph 1: National and state level of core actions where improvements were needed before accreditation was awarded by NSQHS Standard
SA Ambulance Service (SAAS) - 1st ambulance service to go through full accreditation against the NSQHSS in Australia.
National Safety and Quality Health Service Standards
% o
f co
re a
ctio
ns
asse
ssed
as
'no
t m
et'
on
init
ial a
sses
smen
t
2.0%
1.5%
1.0%
0.5%
0.0%
National and state (NSQHSS 4)level of core actions where improvements were needed before accreditation was awarded by NSQHS Standard
Std 1 Std 1(SA)
Std 2 Std 3 Std 4 Std 4(SA)
Std 5 Std 6 Std 7 Std 8 Std 9 Std 10
Our health services meet national standards
Accreditation is one of the most important drives for safety and quality improvement in SA Health.
28 public health services undertook organisational wide assessment with a further 51 undertaking mid-cycle assessment.
SA Health performed well in comparison to the national average on most actions, with all services meeting Standards 2, 5, 6, 7, 8, 9 and 10 on initial assessment.
SA also performed better than the national average for Standard 4 - Medication Safety.
Source: Australian Commission on Safety and Quality in Health Care
page 4South Australian Patient Safety Report for Consumers and the Community 2017
CHALLENGING BEHAVIOUR
The three most common types of incidents (by level 1 Incident Classification) has been consistent over the last three year period.
MEDICATION
1.
PATIENT FALLS AND OTHER INJURIES
2. 3.
Incidents and harm
Patient Incident Management and Open Disclosure Policy Directive and Toolkit were released, with staff and consumer information and resources available.
Online learning is a key training tool for safety and quality
50,964 online eLearning courses on various safety and quality topics were completed in 2016-17.
Consumer information on what to expect from the open disclosure process.
page 5 South Australian Patient Safety Report for Consumers and the Community 2017
Falls prevention
EFFECTIVE STRATEGIES
Health Professional www.sahealth.sa.gov.au/FallsPrevention General www.sahealth.sa.gov.au/Falls
FALLS PREVENTION
People come to health services for care of injuries from FALLS
During health care, FALLS are the MOST NUMEROUS REPORTED incident
SOUTH AUSTRALIA
10x
• Quick POST FALL TEAM REVIEWS
to reduce repeat falls.
• HOURLY ROUNDING especially for patients who have dementia or delirium.
• 100% of services that have
been accredited PASSED Standard 10. Committees and staff should be proud of
this achievement.
• 14,325+ STAFF have completed the online eLearning course on Falls Prevention since its launch in April 2014.
* All data relates to all of South Australia.
were admitted to public hospitals injured AFTER A FALL.
That figure is over
HIGHER than the 1,927 admitted to hospital for
MOTOR VEHICLE INJURIES.
21,120people 395
older people DIED IN HOSPITAL
as a result of injuries from a fall.
LAST YEAR IN SOUTH AUSTRALIA
10,691REPORTED FALLS INCIDENTS in 2016.
OVER 65% of these were people
OVER 65.
is AVERAGE LENGTH OF STAY in hospital for injured older people6.9 D
AY
S
In SA there has been a
STEADY DECLINE in serious falls (SAC1 and 2).
16026.1 (ALL SA) March 2017
2011 level
2016 level
SERIOUS FALLS AVOIDED
Ser
ious
falls
2011 2012 2013 2014 2015 2016
Potentially there have been
358 serious falls AVOIDED.
Years0
50
100
150
200
250
page 6South Australian Patient Safety Report for Consumers and the Community 2017
A reduction in overall harm
The Safety Assessment Code (SAC) assesses the consequence and harm caused and understands how often the type of incident occurs.
SAC 1 and 2 incidents indicate the level of actual harm caused, SAC 3 and 4 incidents indicate emerging trends, issues and opportunities for improvement. This enables a focus on improvement and preventing similar incidents occurring again.
70000
60000
50000
40000
30000
20000
10000
0
Nu
mb
er o
f in
cid
ents
Total Incidents Harm (SAC 1 & 2) as % of total
2012-13 2013-14 2014-15 2015-16 2016-170.0%
1.8%
1.6%
1.4%
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
55207
60408
53776
44103
37683
1.3%
1.0% 1.0%
0.8%
1.6%
Total of incidents in proportion to SAC 1 and 2
Source: Safety Learning System
SAC 3 and 4 incidents indicate emerging trends, issues and opportunities for improvement. This enables a focus on improvement and preventing similar incidents occurring again.
2014- 2015
14.6%
2015-2016
14.1%14.6%
2016-2017
13.9%
The proportion of near-miss, incidents reported has decreased during the last three years.
page 7 South Australian Patient Safety Report for Consumers and the Community 2017
Partnering with Consumers and the Community
Over 700 South Australians partner with SA Health in service planning, designing care, measuring and evaluating health care services.
In total over 15,000 South Australians have been interviewed over the telephone and over 2,300 were surveyed in 2016.
Over 2,700 consumers surveyed on their experience in the health service using a computer assisted personal interview (CAPI) mobile device.
Over 6,600 consumers participated in Happy or Not, monitoring satisfaction on quality of care and performance.
Over 600 “Do you need an interpreter?” posters, guides and interpreter symbols have been displayed in health sites.
Over 4,000 “please arrange an interpreter” wallet cards have been given out to culturally and linguistically diverse consumers.
Over 6,000 Partnering with Consumers and Community online eLearning course completed by staff.
Over 230 people with a lived experience completed the national mental health Services - Your Experience of Services “YES” survey.
70 consumers participated in Consumer Advocacy courses.
page 8South Australian Patient Safety Report for Consumers and the Community 2017
Total number of
feedback:11,710
COMPLIMENT
COMPLAINT
36.1%
58.9%
SUGGESTION
ADVICE
2.6%number:303
number:2952.5%
number: 4,221
number: 6,891
Type of consumer feedback
Method of feedback
Total number of
feedback:11,710
TELEPHONE
FEEDBACK FORM
29.8%22.3%
number: 3,485
number: 2,609
LETTER15.8%
number: 1,851
IN PERSON8.5%
number: 991
OTHER4.8%
number: 560
SLS WEB FORM0.4%
number: 42FAX0.0%number: 5
18.5%number:2,167
93% 87% 88%felt they were TREATED with RESPECT AND DIGNITY during their stay.
said they would RECOMMEND THE HOSPITAL to a relative or friend.
ALMOST
RATED the overall quality of the hospital care as ‘VERY GOOD’ or ‘GOOD’
Our measuring consumer experience telephone survey tells us that the majority of our patients continue to be happy with their level of care.
Consumer feedback
page 9 South Australian Patient Safety Report for Consumers and the Community 2017
Infection control 8 clinical directive and guidelines were developed.
Consumer information sheets developed including: > Antibiotic consumer information sheet containing information for patients and carers on antibiotic medicines used in hospital.
> Two consumer information sheets on preventing infections: in hospital settings and in community healthcare settings.
> Generic “visitor alert” posters to help manage outbreaks of seasonal illnesses such as gastroenteritis or influenza.
The consumer information sheets were reviewed and endorsed by the SA Health Safety and Quality Community Advisory Group.
ASK your healthcare provider if they have cleaned their hands.
STOP smoking;
smoking increases the
risk of infection.
Take action for preventing infection
Visit the website for more information:
www.sahealth.sa.gov.au/hospitalinfections
Infection Prevention and YouYou are an important part of helping to prevent infection
TELL your healthcare provider if your wound or skin around a medical device becomes red, swollen or painful.
DISCOURAGE friends and family from visiting if they are unwell.
REMEMBER
TAKE the full course ofany antibiotics prescribed,even if you feel better.
TALK to your healthcare provider if
you have any concerns.
SA Health Consumer Information
AVOID touching any wound or
medical device (if present).
WASH your hands often, especially after using the toilet and before eating.
KEEP your dressings clean and dry. Inform
your healthcare provider if not secure.
COVER your mouth & nose with a tissue or your elbow when
coughing or sneezing.
WHAT CAN YOU DO TO HELP?
This document has been reviewed and endorsed by SQCAG* for consumers and the community August 2016.
*SA Health Safety and Quality Community Advisory Group.
FIS 16027.2
page 10South Australian Patient Safety Report for Consumers and the Community 2017
BloodSafe eLearning Australia > Three new courses, based on the national PBM Guidelines: Module 5 Obstetrics and Maternity. Courses include; Obstetric Haematology, Obstetric Blood Management and Postpartum Haemorrhage.
> 425,000+ learners registered and 850,000+ courses completed by 30 June 2017.
Consumer brochures were simplified and translated into 18 other languages relating to:
> Information about having a blood transfusion
> Iron and iron deficiency
> Guide to taking iron tablets
> Intravenouse (IV) iron fusions
Medication safetyPocket Drug Committee (DTC) mobile application launched providing timely access to up-to-date information and contacts SA Medicines Formulary, medication policies and guidelines and links to medication related resources.
For more information Safety and Quality UnitDepartment for Health and Wellbeingwww.sahealth.sa.gov.au/SafetyAndQuality
Public - I1-A1
© Department for Health and Wellbeing, Government of South Australia. All rights reserved. FIS: 18035.2 June 2018.
https://creativecommons.org/licenses/by-nc-nd/4.0/
Further information regarding this report or the Safety and Quality Unit is available on the SA Health website www.sahealth.sa.gov.au/safetyandquality.
Additional information on the safety and quality program is available on the Australian Commission on Safety and Quality in Health Care website at www.safetyandquality.gov.au.
