News
New staff at the APSF
28/05/2008
The APSF recently farewelled Technical Director Peter Hibbert who has moved to the UK to work for the NHS as Associate Director, Clinical Teams, Patient Safety Division, National Patient Safety Agency. Peter's role is to manage clinical teams in the areas of primary care, anaesthesia and surgery, maternity and child health, and mental health with the aim of producing clinically foucssed patient safety advice, reports and guidelines. After four and a half productive years at the APSF, we wish him all the best in this challenging new role.
Peter's position has been taken by Dr Tim Schultz, who will continue to work for the Joanna Briggs Institute on a part-time basis.
APSF Annual Report 2006-2007
20/12/2007
The Australian Patient Safety Foundation's Annual Report outlines the resources produced, presentations and papers given and projects undertaken for the financial year 2006-2007.The Collaborations for Translating Evidence into Practice (CTEP) Program
28/06/2007
The inaugural meeting of the “Collaborations for Translating Evidence into Practice” (CTEP) was held at Coogee on June 21-22, 2007. The meeting was attended by 30 influential leaders in health care to discuss proposals to establish clinician led reform of the health system.
The presenters were:
Professor Bill Runciman: An Overview of the problem - an international perspective and Setting priorities: evidence from the USA, UK and Australia
Ian Scott: An Australian perspective
Jeffrey Braithwaite: Evidence for translating evidence into practice
Dr Mike Stein: The Map of Medicine
Professor Alan Pearson: Nursing and aged care guidelines
Dr Annette Pantle: An Australian story
Professor Bruce Barraclough: Issues with surgery
Professor Alan Wolff: Issues with general practice
Professor Cliff Hughes: Issues with medication management
Professor Heather Gibb: Issues with nursing and aged care
A Coogee Charter was agreed by the meeting delegates:
“The aim is to improve safety and quality of healthcare through clinician-led collaborations by setting and implementing national clinical standards to translate evidence into clinical practice and show measurable improvement by 2010.”
This will be done by setting up a series of Collaboratives that are based on specific problems. An open invitation to participate be issued to all with an interest in that area.
The meeting was organised by the Joanna Briggs Institute, the Australian Patient Safety Foundation, the Centre for Clinical Governance Research in Health and kindly hosted by the Centre for Health Informatics at the University of New South Wales. The organisers would like to thank the Western Australian Department of Health, the South Australian Department of Health, The Victorian Department of Human Services and Queensland Health for their financial support.
The APSF Annual Report 2005-06
02/01/2007
The Australian Patient Safety Foundation's Annual Report outlines the resources produced, presentations and papers given and projects undertaken for the financial year 2005-2006 .APSF’s “Anaesthesia Crisis Management Manual Second Edition (2006)
16/11/2006
Following upon the original 1996 publication of the 1st Edition of APSF’s unique, data based collection of anaesthesia crisis management protocols based upon the first 2000 AIMS Anaesthesia incident reports, APSF is pleased to announce the release of the 2nd Edition of this Manual in November 2006.
This 2nd Edition is based upon the first 4000 AIMS Anaesthesia voluntary and anonymous incident reports submitted to APSF from practising anaesthetists in Australia and New Zealand. It contains stepwise protocols for the clinical management of 28 of the most commonly encountered acute clinical situations in anaesthesia practice (including paediatric anaesthesia). Special Appendices deal with adrenaline (and some other) critical dosage calculations and preparations.
The protocols have been “internally validated” against those incident reports relating to each respective crisis where the management and/or outcome were identified as sub-optimal. Rapid access to each protocol is facilitated by attachable adhesive finger tabs. A web-based version of the protocols can be found here.
Requests for copies of this 2nd Edition, at a cost of Aus$20.00 (+ GST within Australia only) and plus postage for overseas orders only, are available by phone, fax, email or mail, via the following contacts:
Australian Patient Safety Foundation
GPO Box 400
Adelaide
South Australia 5001
Phone 61 (0)8 8222 5115
Fax: 61 (0)8 8232 6938
Email: peter.hibbert@apsf.net.au
International Patient Safety Event Classification Stakeholder Consultation
17/08/2006
The World Health Organisation's World Alliance for Patient Safety is embarking upon a consultation process (the "Delphi survey") for the International Patient Safety Event Classification (IPSEC). This process is designed to obtain vitally important feedback on the proposed conceptual framework, concepts and terms.
Practitioners and other experts interested in patient safety are invited to participate in the Delphi survey to ensure we obtain wide-ranging input. Your participation is greatly valued and appreciated.
As a result of the feedback received through the Delphi Survey, the
IPSEC will be further revised. Field testing will commence in 2007. It is envisioned that the finalised version of the IPSEC will be available in 2008.
To access the Delphi survey visit: www.who-ipsec.org
WHO's Patient Safety Home Page can be accessed at:
APSF Summit 2006: From Understanding to Improvement
31/07/2006
The APSF 2006 Summit was held on:
Wednesday, 11 October 2006 at
Brookman Hall, University of South Australia
Speakers and Presentations:
- Prof Tjerk Van der Schaaf: Associate Professor of "Human Factors in Risk Control" Eindhoven University of Technology, The Netherlands and
Associate Professor of "Patient Safety Research"
Leiden University Medical Center Integration of Predictive and Retrospective risk analysis in healthcare -
Dr Jim Battles: Patient Safety Center for Quality Improvement and Patient Safety Agency for Healthcare Research & Quality (AHRQ), USA Where We Have Been? - Where are We Going? The Patient Safety Initiative in the
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Ms Anne Maddock: Director Quality Systems, Royal District Nursing Service (RDNS) South Australia,
(2005 Risk Manager of the Year) Enterprise wide risk management and improving safety and quality in health care -
Prof Penny Sanderson: Professor of Cognitive Engineering and Human Factors at the University of Queensland Supporting anaesthetist situation awareness: New tools, new challenges
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Dr Matthew Thomas: Program Director Human Factors and Safety Management Systems, University of South Australia Error Management in the Organisational Context
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Dr Annette Pantle: Director, Clinical Practice Improvement Projects, New South Wales, Clinical Excellence Commission From understanding to improvement • it’s child’s play. The Children’s Emergency Care Project in NSW
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Prof David Ben-Tovim: Director, Clinical Governance, Flinders Medical Centre Next Steps in Patient Safety; using lean thinking to build safety in, not inspect error out
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Dr Stuart Whittaker, CEO, Council for Health Service Accreditation of Southern Africa Managing Patients with HIV/AIDs Safely in
Delia Dent
Comparing the First and Last 2,000 Anaesthetic Incidents using AIMS
09/02/2006
The APSF receives anonymous paper-based incident reports from anaesthetists in Australia and New Zealand - the APSF has over 8,000 of these reports classfied and another 2,000 waiting classification. The Australian and New Zealand College of Anaesthetists has provided the APSF with a grant to "Compare the latest 2,000 incidents with the first 2,000 to track progress and devise safety strategies for new problems".
The last 2,000 incidents received by the APSF will be classified into the Advanced Incident Management System (AIMS). The types of clinical situations, their circumstances, contributing factors, minimising factors, monitors used, and outcomes will be compared to the first 2,000 incidents. The 30 articles published in the 1993 Anaesthesia and Intensive Care Symposium will be used as the basis of the comparison.
The project commenced in January 2006 and is expected to be completed by the end of the year.
Development of an Conceptual Framework for an International Patient Safety Classification
09/02/2006
The World Health Organisation's Alliance for Patient Safety has asked the APSF to lead the Working Group to develop the Conceptual Framework for an International Patient Safety Classfication. The Working Group will develop and define the high level concepts to ensure that the Classification
complies with the specifications required of all WHO Family of International Classifications.
Other members of the Workgroup include Thomas Perneger, Tjerk van der Schaaf, Richard Thomson, and JCAHO.
WHO has commissioned another group to identify a list of critical concepts to be included in the classification.
APSF Summit 2005: Innovations in Patient Safety for Clinical Leaders
28/09/2005
Aim: To present the latest information so you can implement quality and safety changes at your department or unit.
Wednesday May 18th 2005
Robson Lecture Theatre, Royal Adelaide Hospital
The APSF Summit was held in association with the South Australian Department of Health, the Royal Adelaide Hospital and the University of Adelaide.
The title of the Summit was Innovations in Patient Safety for Clinical Leaders. The Summit recognized that changes in patient safety are very difficult to make and sustain at the interface between clinician and patient. The aim of this Summit was to give clinicians practical ways to implement initiatives at departmental and ward level and to convert existing research into positive change.
The APSF would like to acknowledge the Australian Council of Safety and Quality in HealthCare, for providing support and for inviting Professor Cliff Hughes OAM.
Links to presentations are provided below:
- Mr Jim Birch, Chief Executive, South Australian Department of Health Opening address
- Prof Bob Helmreich, University of Texas Translating quality and safety evidence into meaningful change
- A/Prof Jeffrey Braithwaite, Centre for Clinical Governance, University of New South Wales Changing dysfunctional departments into teams ? navigating culture and politics
- Prof Bill Runciman, Australian Patient Safety Foundation Systems Change vs Clinical Autonomy: is there a way forward?
- Prof Drew Dawson, Centre for Sleep Research, University of South Australia New approaches to fatigue management
- Christy Pirone, Principal Consultant, Safety and Quality, SA Department of Human Services Toolkit: Using Root Cause Analysis techniques at departmental level
- Liz Fitzgerald, Patient Safety Manager, Queen Elizabeth Hospital Toolkit: Using Health Failure Effects Mode at departmental level
- Bernie Harrison, CPI Director, Royal North Shore Toolkit: Clinical Practice Improvement
- A/Prof Howard Galloway, Director of Medical Imaging, The Canberra Hospital Quality Use of Diagnostics (QUDI) Imaging Project
- James Edwards, Head Cardiothoracic Department, Royal Adelaide Hospital Application of Crew Resource Management Techniques in a Teaching Hospital Environment
- Prof Brendon Coventry, Department of Surgery, Royal Adelaide Hospital Hypothetical
Qualified Privilege / Statutory Immunity
28/09/2005
The Australian Incident Monitoring System (AIMS) was declared a Quality Assurance Activity in June 2001 by the Commonwealth Health Minister under Part VC of Section 124X of the Health Insurance Act 1973. The declaration is valid until June 2006. Protection under this legislation is intended to protect:
- The confidentiality of information that identifies information that becomes known solely as a result of the quality assurance activity; and
- people who participate in activities that involve the assessment or evaluation of the quality of health services provided by others.
The APSF is currently consulting with the Australian states and territories to consider the re-declaration of AIMS, and to ensure that all stakeholder's requirements are met.
Root Cause Analysis in Residential Aged Care
28/09/2005
The Quality Outcomes Branch of the Australian Department of Health and Ageing has appointed the Australian Patient Safety Foundation to undertake the Developing the Use of Root Cause Analysis in Residential Aged Care Project.
The aims of the project are to develop a resource that will:
- Identify and define adverse and sentinel events in the residential aged care context;
- Identify when RCA should be used in residential aged care;
- Increase focus on the clinical safety of residents in a residential aged care setting;
- Develop a tool kit on RCA in plain English that is easy to read and apply in residential aged care, to assist staff with the investigation and identification of processes that may be contributing to adverse health outcomes; and
- Identify training needs to implement RCA in residential aged care.
10 Tips for Better and Safer Care in Residential Aged Care
28/09/2005
The Quality Outcomes Branch of the Australian Department of Health and Ageing has contracted the APSF to produce a booklet "10 Tips Guide for Safer and Better Residential Aged Care." This builds on the work of the Australian Council for Safety and Quality in Health Care - in 2003, they produced a booklet titled "10 Tips for Safer Health Care".
The current project aims to adapt and broaden this publication for the aged care setting. It also aims to empower residents and their families by providing quality and easy to understand information on safer living in residential aged care facilities.
Currently, the draft Guide is subject to usability trials with consumer and carer groups.