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

Senior Policy Officer HELEN SMALLWOOD Senior Policy Officer AMELIA DE BIE Policy Officer JOANNA WILLIAMS Senior Policy Officer TBC Project Officer Complaints LISA FORD

Director, Consumers as Partners LOUISE MCKINLAY

Senior Project Officer MEAGAN WARD Senior Project Officer Academy Lead MIRANDA CORNELISSON Senior Project Officer Sentinel Event Coordinator JOANNE MILLER Executive Assistant (shared) Bess Joseph Senior Project Officer Complaints KIM GRATJIOS BANNWART

Incident Response Team: Consumers as Partners Branch

Graduate KAREN HILL Senior Project Officer Complaints ANDREA CALWELL Manager, Consumer Partnerships LIDIA HORVAT Consumer Rep BELINDA MACLEOD SMITH Policy Support Role (T/L) KYLIE FOLTIN Manager, Patient Experience and Outcomes Manager, Incident Response NATHAN FARROW Senior Project Officer Training Lead Rebecca Cooney Graduate BRIANA MASCARO GRIP PhD Student NADIA CHAVES GRIP PhD Student EUNICE WONG Senior Project Officer Academy Support TBC Project Support Officer TBC

5 10 15 20 25 30 35 40 45 50 Wrong patient or body part Suicide in an inpatient unit Retained instrument

• r other material

Intravascular gas embolism Haemolytic blood transfusion reaction Medication error Maternal death Infant discharged to wrong family Other catastrophic: ISR 1 No of SE

2013-2017 Overall SE notifications

2013–14 2014–15 2015–16 2016-17

5 10 15 20 25 30 35 40 45 50 Wrong patient or body part Suicide in an inpatient unit Retained instrument

• r other material

Intravascular gas embolism Haemolytic blood transfusion reaction Medication error Maternal death Infant discharged to wrong family Other catastrophic: ISR 1 No of SE

2013-2017 Overall SE notifications

2013–14 2014–15 2015–16 2016-17

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

2 4 6 8 10 12 14

9 Other - 2016-17

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

Severity of Harm

RCA report submission

RCA reports submitted in 60 days = 41%

30 12 9 10 6 1 2 1 1 5 10 15 20 25 30 35 On time (60 days) 2 weeks overdue 1 month overdue 2 months overdue 3 months overdue 4 months overdue 5 months overdue 7 months overdue 8 months overdue Number submitted

Sentinel Event RCA Report Submission times

0.00 0.50 1.00 1.50 2.00 2.50 3.00 A C D F G J K E H N M P Q

Metropolitin Hopsitals - Rate bed days (per 100,000 bed days) Rate bed days (per

100,000 bed days)

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 incomplete or inadequate, involved the wrong body part (side or site) or the incorrect process, procedure or treatment. 8 Oesophageal intubation (2), complications during or following surgical procedures (6) Involved a diagnosis or assessment that was not performed when indicated or was incomplete of inadequate. 4 Death post discharge from a health service (3), incomplete assessment of a life threatening 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)

Mode Number Patient Status Number Patient absconded from an ED 1 Hanging 2 Jumping in front of train 3 Patient on ground leave within a mental health facility 4 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

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

2 4 6 8 10 12 14 16 18 No of SE

Sentinel events 2016-17 & 2017-18

Incident Response Team.

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