HQSC News & Events

First DHB signs pledge to improve patient safety

Wed, 22 May 2013 10:56:33 +1200

General

Press release from Hon Jo Goodhew

Tairawhiti District Health’s decision to become the first district health board in New Zealand to sign a certificate pledging support for the new national patient safety campaign has been welcomed by Associate Health Minister Jo Goodhew.

“I am delighted that Tairawhiti DHB has become the first in the country to formally sign up to the Open for better care campaign, which aims to save lives and reduce harm,” said Mrs Goodhew.

“This shows their commitment to working in partnership with patients, consumers, families and whānau to reduce patient harm.

“I’d also like to congratulate other DHBs and health providers who have indicated their support for the campaign. I look forward to more DHBs signing the pledge certificate as the campaign progresses.”

The Open for better care campaign was launched by Minister Goodhew on 17 May 2013 and will run to mid-2015. It will focus on four areas where evidence shows it is possible to reduce patient harm – falls, surgery, healthcare associated infections and medication safety.

DHBs signing the certificate pledge to be open to:

working in partnership with patients, consumers, families and whānau
change, improvement and innovation
supporting an honest, transparent and respectful culture
listening carefully and communicating clearly
acknowledging mistakes and learning from them
working as a team and across teams
working across the primary and secondary sector
using evidence-based practice
sharing and learning from successes.

Tairawhiti DHB Board Chair David Scott and Chief Executive Jim Green signed the pledge certificate at a staff morning tea in Gisborne Hospital’s cafeteria on 17 May.

“It is a privilege to be the first DHB in New Zealand to sign this significant pledge – a long-term promise of patient safety,” said Mr Scott.

Mr Green said championing the campaign was the best way for Tairawhiti DHB to focus on improving outcomes for patients. “By signing this pledge, we again commit our energy and resources to improving care while reducing harm.”

Information about the campaign can be found at www.open.hqsc.govt.nz.

Health literacy in community pharmacy

Tue, 21 May 2013 09:45:00 +1200

Consumer Engagement

The Health Quality & Safety Commission is carrying out a health literacy demonstration project with two community pharmacies. Health literacy is the degree to which individuals can obtain, process and understand health information and services they need to make appropriate health decisions.

The demonstration project, which runs until the end of July, provides community pharmacists with training and resources to increase their understanding of health literacy. Subsequently the training resources will be available more widely.

We invite you to help us with this work by taking part in an online survey. It will take less than ten minutes to complete, and everyone who completes the survey will go into a draw to have a chance to win a $150 voucher for a meal for two at a restaurant of the winner’s choice.

All information received will be confidential and held by Malatest International, which is conducting the survey on our behalf.

The survey asks about:

how you communicate with your consumers
your training in and understanding of health literacy
the health literacy environment of the pharmacy you work in.

Please click www.healthliteracy.malatest.net to start the survey (the link will be open from May 24 to June 21).

If you have any questions, please contact Debbie McLeod at Debbie.McLeod@malatest-intl.com or 04 212 4566, or Linda Gilbert at the Health Quality and Safety Commission at Linda.Gilbert@hqsc.govt.nz.

BMJ editorial: Let the patient revolution begin

Tue, 21 May 2013 09:41:47 +1200

Consumer Engagement

This editorial, published in the British Medical Journal (BMJ) recently, discusses the need to work in partnership with patients to improve health care.

Expertise in health and illness lies outside as much as inside medical circles, and working alongside patients and their families is essential to improving health.

The full article can be accessed on the BMJ website.

Interim results of the April Falls national quiz

Fri, 17 May 2013 16:00:00 +1200

Reducing Harm From Falls

The First Annual National April Falls Quiz closed on Friday 10 May 2013 with just under 1500 entries (1483 completed entries were received). Thank you to everyone who participated.

The document below gives a quick interim overview of the results and answers to the quiz, with more in-depth reporting to come soon.

April Falls quiz: interim answers

New campaign encourages health sector to be Open for better care

Fri, 17 May 2013 12:12:00 +1200

General

A national patient safety campaign focusing on reducing harm in the areas of falls, surgery, healthcare associated infections and medication is being launched in Auckland today.

The campaign is coordinated nationally by the Health Quality & Safety Commission (the Commission), and implemented regionally by district health boards (DHBs) and other health providers. It will run until mid-2015.

Called Open for better care, the campaign encourages health care workers to be ‘open’ to achieving sustainable excellence in health care, by being open to acknowledging mistakes and learning from them, open to working closely with patients and consumers, and open to change, improvement and innovation.

Commission Chair Prof Alan Merry says, “In our health and disability system, we have highly skilled, caring and committed doctors, nurses and other health professionals who usually succeed in delivering excellent care. Unfortunately, things occasionally go wrong, and we cannot afford either the human or the financial costs of avoidable harm.

“Doctors, nurses, managers and other health sector workers need to be open to continually striving to do things better,” he says.

“We know that adopting certain behaviours or processes established in other industries will lead to reduced patient harm.

“For example, we know the World Health Organization’s Surgical Safety Checklist improves patient outcomes. The Checklist is a simple tool for avoiding mistakes. It also promotes better communication and planning for things that might go wrong. Checklists are accepted as fundamental for safety in aviation, and it is essential that effective interventions like this are used properly and consistently across the health and disability sector.

“We can’t afford the cost to patients or the financial cost of wasting highly skilled and expensive surgical or medical care because someone did not wash their hands on a ward round, or because a wet floor resulted in a fall and a broken hip, or because an essential drug was not given correctly, at the right time.”

At today’s launch in Auckland each of the four DHB regions – Northern, Midlands, Central and South Island – will showcase their quality and safety initiatives. The Northern region’s First, Do No Harm patient safety campaign, is co-hosting the national launch.

Best practice will be shared through the campaign website, in addition to events, learning sessions, presentations from clinical experts, videos and other resources. DHB regions will implement the interventions that support and improve their existing quality and safety programmes.

Prof Merry says the campaign’s impact will be measured by quality and safety markers. These are made up of process and outcome measures, and the focus will be on demonstrating improvement in both.

“The process measures will show whether the required changes in practice have been made at a local level – for example, giving older patients a falls risk assessment and developing a care plan for them, or demonstrating that people are washing their hands at all of the World Health Organization’s ‘Five Moments for Hand Hygiene’.

“The outcome measures focus on harm and cost to be avoided and will provide information about progress against the core campaign goals of reduced harm and better value from the available resources.”

Prof Merry says the campaign is an opportunity and a call to action for everyone working in health care to ensure all patients receive the care they really need and value, and to get it right first time.

New national patient safety campaign launched

Fri, 17 May 2013 12:11:00 +1200

General

Press release from Hon. Jo Goodhew, Associate Minister of Health

A new national patient safety campaign aimed at saving lives and reducing harm is being launched today by Associate Health Minister Jo Goodhew.

“This new campaign, Open for better care, challenges health care workers to be open to acknowledging mistakes and learning from them, open to working closely with patients and consumers, and open to change, improvement and innovation,” says Mrs Goodhew.

Open for better care is being coordinated nationally by the Health Quality & Safety Commission and implemented regionally by district health boards and other health providers. It will run until mid-2015.

The campaign focuses on four key areas where evidence shows it is possible to reduce patient harm – falls, surgery, healthcare associated infections and medication safety. Each topic will be rolled out sequentially, with falls the first area of focus.

“In our health and disability system, people with extensive knowledge, skills and commitment are already working together to deliver excellent patient care,” Mrs Goodhew says.

“However, we know patients are still being harmed, sometimes with serious and long-term consequences.

“These events can have a devastating impact on patients and families. Even patients at the less serious end of the scale of harm can end up having a longer stay in hospital. There’s also the associated extra cost to the health system.”

The Quality and Safety Markers, developed by the Commission in consultation with clinicians, will be used to measure the campaign’s impact. The first regular progress report on the Markers is planned to be published in June 2013.

Further information can be found at www.open.hqsc.govt.nz.

New Zealand Tall Man lettering list

Mon, 13 May 2013 09:43:00 +1200

Medication Safety

Work on the national Tall Man lettering list has started.

Over 280 pairs of confusable medicines names have been submitted by health professionals and organisations in New Zealand for review. This list has been culled for duplicates as well as being separated out into generic and trade names.

A sub group of the national medication safety expert advisory group will be assessing pairs of confusable medicines not already assessed under the Australian Tall Man Lettering Standard in the next month. A number of confusable pairs relate to trade names, and decisions will be made about whether to include these in the national list due to the changeability of the names. The risk assessment methodology will be in accordance with the Australian Standard. Work is on track and still expected to be completed by end of June.

For more information, contact Emma Forbes, Senior Project Manager – Medication Safety on 04 901 6055.

National Global Trigger Tool workshop

Mon, 13 May 2013 09:07:00 +1200

Other Topics

The Health Quality & Safety Commission, in conjunction with First, Do No Harm, held a national global trigger tool (GTT) workshop at Ko Awatea on Friday 19 April.

Fifty-three people attended the workshop including participants from sixteen district health boards (DHBs) and representatives from the Commission and First, Do No Harm.

The workshop included short presentations and group discussions which were focussed on learning more about the GTT process and how to use the information for improvement.

Speakers included:

Sharon Walsh, National Standards and Clinical Governance Coordinator, Melbourne Health
Gillian Robb, GTT Clinical Lead
Colin McArthur, Medical Advisor for Quality & Safety at Auckland DHB
Linda Holman, Quality leader for Manaia Health

DHBs also shared their experiences with GTT through the use of story boards.

GTT is a cost-effective way to identify opportunities for improvement, and workshop attendees were enthusiastic about the system and what it can offer in terms of understanding the more common harms experienced by patients.

Commission GTT clinical lead, Gillian Robb, says the evaluation of the workshop was overwhelmingly positive. Gillian Robb acknowledges that there is work to be done to better support DHBs who are using the GTT, including looking at database options and ways to share questions about tricky cases.

Videos, presentations and story boards from the workshop are available below. These have been made available with the permission of the presenters, so we as that if they are used in any way, due acknowledgement is given.

May 2013 'Medication Safety Watch' out now

Fri, 10 May 2013 08:50:00 +1200

Medication Safety

The May 2013 edition of the Medication Safety Watch is now available. This bulletin is for health professionals and health care managers working with medicines or patient safety. It contains information about medicine-related incidents, errors and adverse drug reactions and offers recommendations on how to improve medication safety.

Key messages in this issue:

Health literacy and medication safety
Leading zero clarification
Critical evidence for Making Health Care Safer II
Incidents and cautions.

Click the link below to go to a downloadable pdf of the Medication Safety Watch.

Health Workforce NZ May 2013 Stakeholder Bulletin

Fri, 10 May 2013 08:18:00 +1200

General

The Health Workforce New Zealand May 2013 bulletin for stakeholders is available below. This edition of bulletin includes information on:

Voluntary Bonding Scheme
Advanced Trainee Fellowship
Summer studentships
Review of Health Practitioners Competence Assurance Act 2003

HWNZ May 2013 stakeholder bulletin

The dynamic face of perioperative nursing

Thu, 09 May 2013 09:52:00 +1200

Reducing Perioperative Harm

Delegates attending the conference will be perioperative nurses and other health professionals interested in perioperative nursing working throughout New Zealand within the health sector.

For more information visit the conference website: http://www.periop2013.co.nz/.

National Division of Infection Control Nurses conference

Thu, 09 May 2013 09:50:00 +1200

Infection Prevention & Control

Meet and learn from international and nationally renowned experts, as well as our own infection control personnel. The conference will create an opportunity for networking, collaboration and sharing of information. You will be able to consider the achievements in science, technology, and practice and discern the advances still to come.

For more information visit the conference website: http://www.ipcnc2013.org/home.

Conference for General Practice

Thu, 09 May 2013 09:47:00 +1200

General

Conference for General Practice from the Royal New Zealand College of General Practitioners, Generalism: The heart of health care.

The College is excited to offer a three day conference that features motivational keynote speakers, peer-reviewed scientific research, depth and variety of presentations and workshops focused on practical aspects of general practice – and of course the all-important networking opportunities for everyone.

For more information visit the conference website: http://www.conference.co.nz/gp13.

Third national disability conference

Thu, 09 May 2013 09:43:00 +1200

Consumer Engagement

The third national disability conference from the Health and Disability Commissioner "Another complaint, another improvement. Towards better disability services."

Come and hear about the significance of 'speaking up'
Learn how making a complaint can help you and others
Find out how to turn complaints into a quality improvement tool

Speakers/presenters include:

Laurie Harkin (AM) - Disability Services Commissioner, Victoria, Australia
Anthony Hill - Health and Disability Commissioner
Paul Gibson - Disability Rights Commissioner, Human Rights Commission
Leaders of New Zealand's disability sector

Other conference highlights:

Informative sessions for consumers, service providers and professionals alike
Opportunities for networking with key people in the sector
Interactive sessions offering opportunities for discussion and questions
Trade display of disability-related products and services, and
Lots of fun and entertainment including dance and music workshops.

The Commission is sponsoring 20 consumers to attend the conference. For more information click here.

New Zealand Medical Association GPCME South

Thu, 09 May 2013 09:37:00 +1200

General

The programme will provide a general practice update, with short, sharp and to the point clinical content, including key take home messages to change practice behaviour immediately.

For more information visit the conference website: http://www.gpcme.co.nz/south/index.php.

New Zealand Medical Association GPCME

Thu, 09 May 2013 09:35:00 +1200

General

The programme will provide a general practice update, with short, sharp and to the point clinical content, including key take home messages to change practice behaviour immediately.

For more information see: http://www.gpcme.co.nz/.

Consumer subsidy to attend Health and Disability Commissioner conference

Thu, 09 May 2013 09:08:00 +1200

Consumer Engagement

Consumers interested in attending the third annual Health and Disability Commissioner (HDC) conference on Monday 17 June, can apply for subsidised registration from the Health Quality & Safety Commission.

20 spots are available to consumers and their family members or unpaid carers.

If you are a consumer or family member/unpaid carer and would benefit from subsidised registration to the conference, please contact Vanessa Creamer or Hemant Thakkar at the HDC on 0800 112 233.

Download the registration form here.

New list of patient safety practices released

Tue, 07 May 2013 12:37:00 +1200

Medication Safety

The Agency for Healthcare Research and Quality (AHRQ) has updated its list analysing the strength of evidence for patient safety practices.

AHRQ has released Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. The new report is an update of the AHRQ’s 2001 report, Making Health Care Safer: A Critical Analysis of Patient Safety Practices.

In its latest report, the AHRQ analyses the growing body of patient safety research to determine the evidence for the outcomes of safety strategies. It also looks at the implementation, adoption and context of using safety strategies.

After analysing 41 patient safety practices, an international panel of safety experts identified 22 strategies that are ready for adoption. The strategies were chosen on the basis that enough evidence exists to advise health systems and institutions to begin implementing them to improve the safety and quality of health care.

The 22 recommended strategies include the “Do Not Use” list for hazardous abbreviations (the Commission’s version of this list is called “Error-prone”).

Making Health Care Safer II also identifies 12 patients safety strategies that health systems and institutions are encouraged to adopt based on the strength and quality of evidence. The list of 12 strategies includes medicine reconciliation.

For the full list of safety strategies in Making Health Care Safer II, see the AHRQ website.

April Falls quiz still open for entries

Tue, 07 May 2013 10:02:00 +1200

Reducing Harm From Falls

The quiz is an engaging way for people to test their knowledge about falls, while measuring sector knowledge of falls risks and prevention. The findings will provide the Commission with a baseline for comparison in subsequent years. The quiz is open to anyone interested in falls prevention and reducing harm from falls, and can be entered online until Friday 10 May.

The questions cover attitudes to falls, as well as their causes, impacts for the individual, knowledge of risk factors and effective interventions. Findings will be reported at the launch of the national patient safety campaign on 17 May. Participants will receive fortnightly text or email alerts which will link to falls ‘hot topics’ on the Commission’s website throughout the campaign.

All quiz entries qualify for a prize of professional development to the value of $1000, for example, conference registration for the 2013 Asia Pacific (APAC) Forum in Auckland or the 2014 Australia New Zealand Falls Prevention Society conference in Sydney. The prize will be awarded to an individual entry selected at random. There is a second prize of one free registration to the APAC Forum for the first workplace to submit 20 survey entries.

The quiz can be accessed here.

National Health IT Board May 2013 newsletter

Fri, 03 May 2013 15:22:00 +1200

General

The May 2013 issue of the National IT Health Board newsletter Towards 2014 is now available online. In this issue:

Clinican's corner
Update on regional clinical workstations
Patient portals: the way of the future
Patient portal offers benefits to Auckland practice
Patient portal makes life easier for Wellington patient
People at the heart of clinical change project
HISO - new Chair and update on work
Website survey

Click here to read the newsletter.