Page 1979 - Week 06 - Tuesday, 5 June 2018
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To confirm the effectiveness of these strategies, an organisation-wide audit is occurring to review a number of practices, including positive patient ID and clinical handover. Appropriately, immediate feedback and education are being provided throughout the audits to improve ongoing practice.
Results are being collated and analysed to provide targeted education, training and focused improvement work where needed. I understand the interim director-general has also written to managers at Canberra Hospital asking them to ensure that their staff are compliant with positive patient ID policy and procedure.
The surveyors also found errors in specimen labelling. A number of measures have been implemented to address specimen labelling errors. Positive patient identification is being included in clinical handover training sessions and the clinical safety and quality unit has completed audits of clinical handover in operational areas.
A zero-tolerance policy for the majority of pathology mislabelling incidents is to be implemented. This would exclude precious samples, which are those that would cause more harm than good to re-collect or those that cannot be re-collected, such as from amputated limbs. The Chief Medical Officer has contacted all junior doctors advising that a zero-tolerance policy is being developed and to comply when labelling specimens by using three identifiers.
At the time of the survey, the completion of surgical safety checklists was below the 100 per cent required under CHHS policy. These checklists are important to ensure the safety of patients when they leave the operating theatre. ACT Health is conducting weekly audits to ensure compliance with completing the surgical safety checklist. As of 25 May, that compliance was at 95.11 per cent. This is now well above the 79.8 per cent observed by the ACHS in March and getting closer to the necessary 100 per cent.
There is ongoing communication underway between the Executive Director for the Division of Surgery and Oral Health and non-compliant surgeons to ensure that this is further improved. This is being taken very seriously by ACT Health, with an escalation approach to managing the performance of any doctor identified as not complying with these essential standards and work practices.
The ACHS assessed ACT Health as having two core actions not met under standard 6, which relates to clinical handover. Unfortunately, the surveyor observed inconsistent use of evidence-based handover processes to ensure safe and effective clinical handover is observed across the organisation. Handover is an important clinical communications tool so that the clinical team are abreast of the care and clinical needs of patients so they can plan the next stages of care and what is required for discharge.
A number of steps are being taken to address this. The clinical handover policy has been updated and an education plan is being developed and implemented. Workshops to train senior staff in patient identification and clinical handover have commenced. To remind staff of the core elements of effective clinical handover, identification, situation, background assessment and recommendation—ISBAR—lanyards and
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