High Level Incident Overviews and Strategies
It is an unfortunate reality that complex health care delivery is never free from risk or error. This is recognised by the World Health Organisation, which acknowledges that healthcare errors can cause unintentional harm and are, at times, associated with poor patient outcomes.
EMHS staff are encouraged to prioritise continuous learning and improvement that supports the ongoing delivery of high-quality care.
We foster a proactive and transparent patient safety culture that uses a non-punitive approach to the reporting of, and learning from, clinical incidents or errors.
Every clinical incident is assigned a Severity Assessment Code (SAC) rating, which determines the investigation method to be applied. Clinical incidents that result in serious harm or death (SAC 1) trigger a rigorous investigation facilitated by an expert panel. Members of this panel may be completely independent to the health service.
Measuring high level incident overviews and strategies
Clinical incidents are calculated at a rate per 1,000 occupied bed days. This helps us understand how busy a hospital is at the time of an incident and indicates how successful the culture of open and transparent reporting is.
We aim to learn from every incident, whether it causes harm or not, and make changes to systems, processes and procedures to reduce the risk of a repeat occurrence.
How do we measure up
The graph below shows the combined incident rate for the EMHS hospitals:
- Armadale Health Service
- Kalamunda Hospital
- Bentley Hospital
- Royal Perth Hospital
Chart: Rate of reporting of clinical incidents per 1,000 occupied bed days: All reported inpatient clinical incidents and inpatient clinical incidents resulting in harm.
What the figures mean
The dark green bar shows the total rate of all inpatient clinical incidents, while the lighter bar illustrates the number of incidents that resulted in harm of any kind.
The higher total rate of reported incidents and the consistently high rate of reporting shows that the reporting culture is healthy and effective. Importantly, the rate of incidents resulting in harm has remained low, which shows that we are learning from events and introducing effective programs to prevent and minimise harm.Learning from Clinical Incidents
Situation
In incidents where patient(s) require an iron infusion to correct iron deficiency, the treating doctor will explain the procedure including discussing the risk factors and then obtains the patient consent to the procedure. An intravenous cannula (IV) is inserted into the patient’s arm in order to administer the iron infusion. This procedure carries a risk that the IV cannula can dislodge and make its way out of the vein leading to a small amount of iron entering the tissue surrounding the IV site. When this is discovered the iron infusion is stopped immediately. The patient’s doctor is then notified and the incident is discussed with the patient. As a result, the patient(s) can experience permanent iron staining to the surrounding skin.
Recommendation
It was recommended that EMHS introduce an iron infusion guideline to enhance the existing Iron Infusion Consent and Checklist form and the Intravenous Iron Infusion Patient Information Leaflet. The guideline is to cover prescribing, supply, administration and monitoring of intravenous iron products.
Result
EMHS introduced an Intravenous Iron Therapy – Adult Guideline to assist staff in administering iron infusions according to evidence-based practice. The guideline was reviewed by stakeholders across EMHS to ensure consistency in practice across multiple sites. Additional training and awareness to support staff was also introduced.