Patient safety in Victorian hospitals

The Victorian Auditor General’s report (March 2016) was released today.

The comments on page vii are less than positive, noting:

The audit found that there have been systemic failures by DHHS, indicating a lack of effective leadership and oversight which collectively pose an unacceptably high risk to patient safety. Some of these issues were identified over 10 years ago in our 2005 audit. These include failing to comply with its patient safety framework, not having an effective statewide incident reporting system and not using patient safety data effectively to identify overall patient safety trends.

DHHS is not giving sufficient priority to patient safety. In doing so, it is failing to adequately protect the safety of hospital patients. DHHS has also not effectively collaborated with VMIA, and this has hindered the authority’s ability to optimise its support to hospitals.

While some data exist that indicate improvement in patient safety in Victorian public hospitals, such as reductions in insurance claims and infection rates, these are only indicative. This means that neither DHHS nor the hospitals can know whether overall patient safety outcomes have improved.

Thirteen recommendations were made, as follows:

That the Department of Health & Human Services, as a matter of priority:

1. reviews, updates and complies with its 2011 Adverse Events Framework, including incorporating a robust data intelligence strategy
2. implements an effective statewide clinical incident reporting system
3. aggregates, integrates and systematically analyses the
clinical incident data it receives from different sources
4. implements a process for health services to report both sentinel events and an absence of sentinel events
5. promptly disseminates lessons learnt from sentinel events to health services
6. includes meaningful indicators in its performance assessment score, such as morbidity and mortality rates
7. shares patient safety data with other government agencies that have a stake in improving patient safety.

That health services:

8. ensure timely feedback is provided to those who report incidents on the recommendations from incident investigations and the outcome of actions implemented
9. evaluate all recommendations from incident investigations for effectiveness to assess whether they are appropriate, are achieving the intended results and are sustainable, as per the Department of Health & Human Services’ revised Victorian health incident management policy and guide
10. ensure review of ISR3 and ISR4 patient safety incidents to identify all risk-prevention opportunities to better quantify and understand the prevalence and impact of these incidents
11. ensure that incident investigations comply with the Department of Health & Human Services’ policy and guidance.

That the Department of Health & Human Services, as a matter of priority:

12. in collaboration with health services, improves training in incident investigations, including comprehensive root cause analysis, in-depth case review training programs and review of lower severity incidents
13. reviews its 2011 Victorian health incident management policy and associated guide, including developing guidance on evaluating the effectiveness of recommended actions from investigations.

With thanks to Janine McIlwraith for noting this material.


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