Portland District Health Annual Report 2005 - South West Alliance of ...

More documents

Recommendations

Info

findings in other organisations, development ofappropriate policies and procedures are just someof the areas that are examined in this clinical riskmanagement program.During the past year the clinical risk managementprogram has been further strengthened byimprovements in the following risk areas:• Credentialing & scope of practice• Participation in the Limited Adverse OccurrenceScreening’ (LAOS) Project• Clinical case reviews.• Root cause analysis of medication incidents.• Falls prevention• Wound management• Sharps incidents• Infection controlCredentials and Scope of Practice -Medical StaffIn order to provide good professional performanceand minimise clinical risk it is vital that our medicalofficers and staff are qualified to undertake theirduties.For example only suitably qualified medical staffare permitted to perform anaesthetics or undertakeobstetrics within the hospital.This process, known as credentialing, occurs beforea medical staff member is appointed. A specialistcommittee comprised only of medical staff undertakesthis. A representative of the appropriate College is inattendance to provide independent expert advice.The credentialing committee checks and advises thehospital’s Medical Appointments Advisory Committeeas to whether an applicant is suitably qualified forthe position they have applied for. This committeealso advises as to what limitations to practice shouldapply.During the year, a discussion document was preparedoutlining the Clinical Scope of Practice for alldisciplines of the Portland District Health medicalworkforce. This document was accepted by all VMOsand incorporated into the Credentialing policy. Thecredentialing process was conducted incorporatingthe guidelines from the Australian Council forSafety and Quality in Health Care. In all disciplinesrepresentatives of the relevant colleges were inattendance to comment on the college requirementsfor credentialing.Portland District Health has completed this processand all VMOs of the service, are fully credentialed towork within their limitations (scope of practice). Theprocess is ongoing and all VMOs will be credentialedevery 3 years, to ensure that all disciplines complywith the quality and safety standards of PDH.‘Limited Adverse Occurrence Screening’ (LAOS)ProjectPortland District Health has been participating inthe Otway Division of General Practice “LimitedAdverse Occurrence Screening” (LAOS) Projectfor approximately 2½ years. This Clinical RiskManagement Program is part of the Departmentof Human Services Strategy for “Improving PatientSafety in Victorian Hospitals”. The project has beenimplemented across the state (in Rural Victoria), andfrom this, we are starting to see state-wide trends inissues in patient safety.A selection of medical records are copied and sent offsite to a doctor in another area for review. Doctorsfrom other towns provide feedback on our care, toensure that we are doing our best. Your own doctormay also be involved. Educational issues arisingfrom the record may then be discussed confidentiallyby doctors at a quality improvement meeting. Thisallows clinical lessons to be learned and shared withother doctors, hospitals and services across the region.Your personal information is not collated, reproduced,published or used for any other purpose.Recommendations on clinical and systems issuesare discussed at hospital quality forums, theserecommendations are responded to by each individualhospital. The recommendations are forwarded to allthe General Practitioners and hospital Chief ExecutiveOfficers participating in the program.Since the last Quality of Care Report (12 months ago),603 records have been received from the 10 hospitalsparticipating. Of these 603 records, 38 cases wereregarded as potentially containing an adverse eventand 57 cases were regarded as presenting educationalopportunities.Some issues resulting in recommendations in this lastyear have included:• GP management of patients with unstableangina• Registrar training and supervision• Dealing with a poorly compliant patient• Home Medicines Review Program• Warfarin Guidelines• Training for patient decision making in PalliativeCare• Reviews of hospital narcotics and major traumaprotocols12
This process in Risk Management cannot find and fixall problems in relation to patient safety in Hospitals,it does however, aim to provide us with a snap shot ofwhat GPs see as our most pressing problems in RuralHospitals.Through consultation and working together, wecan look at ways to best address these issues, to thebenefit of all. Therefore by sharing experiences at 10small rural hospitals the philosophy of learning fromeach other’s mistakes, and putting systems in placeto prevent the same problems recurring elsewhere,resulting in a happier, healthier community.Clinical Case ReviewsAnother tool utilised in quality of care improvement isthat of clinical case reviews. It is a no-blame approachwith the aim of improving health outcomes.The Director of Medical Services, Dr Meindert vander Veer has conducted 10 reviews. These reviews aremultidisciplinary and involve doctors, nurses andsupport personnel. As a result of these reviews, systemerrors are identified and rectified.Several areas of improvement have been identifiedincluding:• Equipment management• Policy or procedure review• Documentation standards• Staff educationBetter Practice in Medication ManagementIn 2005 Portland District Health introduced aPharmacy Nurse position into the Pharmacy Serviceas a result of an identified clinical risk gap, to improvethe organisation’s performance in medicationmanagement.Patients Receiving Medication Counselling 20051009080706050403020100Feb March April May JuneFig. 1Pharmacist, Glen Bennet - Hullin.Patients are vulnerable to mistakes being made in themany steps involved in the ordering, dispensing andadministration of medications.There are many causes of medication error some ofwhich may be – inadequate knowledge of patientsand their condition, inadequate knowledge ofmedications, calculation errors, illegible handwriting,and confusion regarding medication names.Best practice indicates that admission should providean opportunity for all patients to have their medicationsreviewed. A criteria was developed to screen patientsat most risk of medication problems – age over 75,on four or more medications, on medications with anarrow therapeutic window eg Warfarin, referred byadmitting doctor.The target for patients meeting the criteria to receivemedication counselling was set at 90%; this wasexceeded in 3 out of the 5 months.In response to a growing number of medicationincidents the Pharmacist, Director of Medical Servicesand the pharmacy nurse now perform a Root CauseAnalysis (RCA) of all medication incidents.Utilising a no blame approach, all medicationincidents are analysed to identify the system errorleading to the event.Staff involved are debriefed, counselled and educated,learning from the errors thus reducing the risksassociated with administering medications.13
Page 1 and 2: Portland District HealthAnnual & Qu
Page 3: PORTLAND DISTRICT HEALTH2nd Annual
Page 6 and 7: DIRECTOR OFMEDICAL SERVICESAudiolog
Page 8 and 9: President & Chief Executive Officer
Page 10 and 11: Primary Care ServicesOur primary ca
Page 12 and 13: Services provided in 2004/05During
Page 16 and 17: Patient Education - MedicationsInvo
Page 18 and 19: Complaints and ComplimentsBecause y
Page 20 and 21: During the hospital stay there is a
Page 22 and 23: usy year. 364 client’s accessed s
Page 24 and 25: The increased demands for documenta
Page 26 and 27: Medical Services DivisionKey Points
Page 28 and 29: Primary and Community Health Servic
Page 30 and 31: Shire, Windamara, Dhauwurd-WurrungA
Page 32 and 33: Performance2005 has seen the birth
Page 34 and 35: activity was held at the Portland K
Page 36 and 37: We would like to thank the Engineer
Page 38 and 39: information that will help us to en
Page 40 and 41: Sea View House ~ A Resident’s Vie
Page 42 and 43: Comparative Statistics for the Past
Page 44 and 45: Comparative Financial Analysis2003/
Page 46 and 47: Officers and Office BearersNursing
Page 48 and 49: Donors & SponsorsDonors $ $Dipalo,
Page 50 and 51: This page has been left blank inten
Page 52 and 53: Portland District HealthAccountable
Page 54 and 55: Portland District HealthStatement o
Page 56 and 57: Portland District HealthNotes to an
Page 64 and 65:
Portland District HealthNotes to an
Page 66 and 67:
Page 68 and 69:
Page 70 and 71:
Page 72 and 73:
Page 74:
show all

Portland District Health Annual Report 2005 - South West Alliance of ...

Create successful ePaper yourself

Delete template?

Save as template?