Building for a brighter future - GHA Central

Review of Operations: Quality Report
In response to learning from
others in healthcare across
Australia, WGHG has:
➤ Reviewed blood transfusion
practices in line with best practice
models
➤ Introduced best practice use of
pain relievers in the Emergency
department
➤ Implemented the Surgical
Consultative Council five step
patient identification processes to
help ensure we have the correct
patient for the correct procedure
A heightened awareness
of procedures and
encouragement to report,
has resulted in staff
reporting more errors in
medication documents.
This positive increase
indicates errors are being
picked up before the
medications are given,
preventing potential harm.
Medication management
In 2004-05, after a review of the most
common forms of medication error,
we concentrated on how medications
could be unintentionally omitted.
Improvement strategies implemented
dramatically improved the number
of errors relating to the omission of
medications by 66%.
In 2005-06 the focus was on
errors relating to documentation.
Medication incidents are regularly
discussed at Nursing Council meetings
and in the Medication Safety Working
Party so that improvement strategies
can be targeted in the most effective
manner.
This year:
➤ Clinical Nurse Managers changed
handover processes to include
checking of medications at the
bedside for all Ward areas
➤ The medication management
procedure was reviewed
➤ All nursing staff received in-service
training on medication management
procedures and general incident
reporting
➤ In a “no-blame” culture, staff were
actively encouraged to report all
documentation errors detected.
The data for 2005-06 now shows
a 129% increase in the number
of incidents reported (31 to 71).
Of the 71 reported incidents in
this category, only one had a minor
outcome requiring medical review
for the patient.
Another project aimed at reducing
medication errors by targeting the
way medications are documented,
commenced in 2004-05 when
WGHG trialled a standardised
national medication chart and
provided feedback to the National
Quality And Safety Council, National
Medication Chart pilot project. This
year the National Medication Chart
was fully implemented at WGHG.
Pharmacist Kenneth Ch’ng ensures
the medications prescribed on the
medication chart are the correct medication
prior to discharge of patient Arthur Row.
Falls
Falls remain one of the top two
incidents reported at WGHG.
Falls projects, commenced last year,
continue with best practice falls risk
assessments and minimisation
strategies being implemented in
all clinical areas and extending into
the community. As part of this, a new
Admission and Discharge form that
includes an initial falls screening tool
was trialled and implemented. If the
initial screen confirms a risk of falling
a second more extensive tool is
completed and falls reduction
strategies implemented in the care
planning.
Analysis of the data shows we are
making a difference. This year there
has been a 17% decrease in the
number of falls occurring in hospital
resulting in minor injuries in the acute
Types of Medication Errors Reported
80
70
60
50
40
30
20
10
0
2003/04
2004/05
2005/06
Omitted dose
Documentation related
Wrong dose
Not detailed
Wrong drug
Duplicated dose
Wrong rate
IV therapy and Site issues
Delayed dose
Wrong patient
Known allergy
Wrong route
Self administering
Adverse drug reaction
Drug intervention
Incompatible blood product
Overall the number of errors reported for 2005-2006, in nearly all categories, has increased. Staff have been provided with a series of incident
reporting sessions to encourage reporting. This has improved the climate of reporting and has given us more opportunities to learn.
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