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Giving A Voice To Patient

Safety In New South Wales

The Centre for Clinical Governance Research in Health undertakes strategic research, evaluations
and research-based projects of national and international standing with a core interest to
investigate health sector issues of policy, culture, systems, governance and leadership.

CENTRE FOR CLINICAL


GOVERNANCE RESEARCH
First published in 2007 by the Centre for Clinical Governance Research, University of New South
Wales, Sydney, NSW 2052. Printed and bound by the University of New South Wales.

© Jeffrey Braithwaite, Joanne Travaglia, Peter Nugus 2007

This book is copyright. Apart from any fair dealing for the purposes of private study, research,
criticism or review as permitted under the Copyright Act, no part may be reproduced, stored
in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without prior written permission.

Enquiries may be made to University of New South Wales.

National Library of Australia


Cataloguing-in-Publication data:
Braithwaite, Jeffrey
Giving a voice to patient safety in New South Wales

Bibliography

ISBN: 978 0 7334 2532 5

I. Braithwaite, Jeffrey II. Travaglia, Joanne Francis III. Nugus, Peter IV. University of New
South Wales. Centre for Clinical Governance Research. V. Giving a voice to patient safety
in New South Wales.

design Layout and printing by UNSW Publishing and printing services 39014


Contents
1 Summary 3

2 Introduction 4

2.1 Patient safety as a core health care problem 4


2.2 Tackling patient safety 5
2.3 Giving a voice to patient safety 6

3 Methods 7

3.1 Sample and procedure 7


3.2 Participants’ characteristics 8
3.1 Focus group method and content 11
3.2 Analysis of focus group data 11

4 Findings 12

4.1 In terms of patient safety, what keeps you awake at night? 12


4.2 Have your concerns about patient safety changed in recent years? 15
4.3 Do you think there are people or groups who are at higher risk (than others)
in the health system? 18
4.4 Can you tell me about the last incident that you observed or heard about that
caused harm to a patient or prolonged their care? 20
4.5 What are we doing well in relation to patient safety? 24
4.6 What key factors prevent improvements to patient safety? 30
4.7 If you could do one thing to improve patient safety, what would it be? 33
4.8 Have you heard about the Institute for Clinical Excellence (ICE), now the
Clinical Excellence Commission (CEC)? 35
4.9 Additional comments 38

5 Discussion 40

6 Conclusion 41

7 References 42

8 Appendices 46

8.1 Appendix 1: Summary of focus group questions 46


8.2 Appendix 2: Demographic questionnaire 47
8.3 Appendix 3: Handout 1 - rates of adverse events 48
8.4 Appendix 4: Handout 2 - responses to patient safety 50
8.5 Appendix 5: Handout 3 - patient safety strategies 51
 Giving a voice to patient safety in New South Wales


1 Summary

This monograph is the final in a series prepared by the Centre for Clinical Governance Research (CCGR)
at the University of New South Wales (UNSW) for the Clinical Excellence Commission (CEC). In the first
two monographs, we reviewed the technical literature on patient safety (Hindle, Braithwaite and Iedema,
2005) and examined major Australian and international patient safety inquiries (Hindle, Braithwaite,
Travaglia and Iedema, 2006). The aim of the series is to shed light on what has become one of the most
important questions in health care practice and management: what do we know about patient safety and
what we can do about it?

This is a social scientific as opposed to a scientific study. We did not design a randomised trial or run an
experiment. Instead, we did something more simple, perhaps more telling: we asked people at the coalface
to talk to us about their concerns about patient safety, what they thought was being done well and what we
could do to make things better. It is very important to capture real life experiences and views in this way,
in order to understand what is going on in the health system from the standpoint of the stakeholder groups
themselves.

In this study we gathered the views of nurses, doctors, pharmacists, allied health professionals, academics
and managers in 30 focus groups across NSW. In total 195 people added their voice to the study. Some
participants were recent graduates; most were senior clinicians and executives. Some of the focus
groups came together as a single discipline; the majority was constituted in mixed groups. We explored
their experiences, sought their opinions about the causes of and possible solutions to breakdowns in
patient safety, and asked them what they thought it would take to achieve the goal of reducing errors and
improving safety for all patients. In answering these questions, participants provided valuable insights into
the ways in which significant cultural change, leading to improved patient safety, might be achieved.

The information presented in this report shows that patient safety is a problem requiring cohesive and
coordinated solutions. Participants were strongly committed to the current direction and strategies for
addressing medical errors and adverse events, and believed that more work can and should be done.
There was a firm belief that patient safety problems occurred not so much as a result of individual error,
but rather as a result of a combination of poor communication, ineffective teamwork, cultural barriers and
inadequate or inappropriate resource management.

Participants had clear views about the role, and more especially the approach, that the CEC should take
within this context. The CEC, they felt, should take a proactive, strategic and consultative approach, and
one which is inclusive of all stakeholders - patients, their carers and families, and health professionals.

In addition, participants thought that the central issues for patient safety were communication and workforce
and workload matters. There was strong support for current initiatives to improve the governance of the
health system, and provide responses to patient safety issues.
 Giving a voice to patient safety in New South Wales

2 Introduction

2.1 Patient safety as a core health care problem


Sparked by a series of international inquiries and reports into medical errors and adverse events,
patient safety has become one of the defining movements in health care in the late 20th and early
21st centuries (Bleich, 2005). At all levels of health services including the World Health Organisation
(WHO), policy-makers, bureaucrats, managers and clinicians, there is concern about the causes
and rates of harm. Many people are committed to improving patient safety. Despite this commitment,
health systems, services and professionals are struggling to find ways to reduce the incidence of
critical incidents and adverse events (Leape, Berwick, Bates, 2002; Watcher, 2004). This is proving
to be what is sometimes called a “wicked problem” – one that is resistant to policy efforts, and is
hard to address (Rittel and Webber, 1973).

This monograph is the third in a series produced by CCGR for the CEC. In the first two monographs,
we reviewed the technical literature on patient safety (Hindle, Braithwaite and Iedema, 2005) and
examined major Australian and international patient safety inquiries (Hindle, Braithwaite, Travaglia
and Iedema, 2006). The aim of the series is to shed light on what has become one of the most
important questions in health care practice and management: what do we know about patient safety
and what can we do about it?

In this monograph we examine some of the human dimensions of this issue. In order to understand
and respond to the causes and consequences of adverse events, it is vital for us to document the
experiences and concerns of health professionals who are, along with patients, at the centre of the
incidents causing harm and the efforts to prevent them (Wu, 2000). This has become particularly
important since reviews of patient safety over the last five years have come to the same conclusion:
progress has been made, but it is limited, patchy and slow, and significant developments in both
research and practice are required (Watcher, 2004; Bleich, 2005; Longo, Hewett, Ge and Schubert,
2005; Leape and Berwick, 2005; Braithwaite, Westbrook, Travaglia, Iedema, Mallock, Long, Nugus,
Forsyth, Jorm and Pawsey, in press; Iedema, Jorm, Long, Braithwaite, Travaglia and Westbrook,
2006).

In addressing this fundamental question of why, after all that we know about the causes and
consequences of patient harm, the rate of progress remains slow, Pauker, Zane and Salem (2005)
invoke the theory of constraints. Most individuals (and systems), they argue, resist change in
some form or another. Factors can include difficulties in negotiating what to do, politics, lack of
resources, insufficient training or poor implementation. In order to facilitate the desired change, six
key conditions must be met. There must be agreement: first, that there is a problem; second, on its
duration; third that the proposed resolutions will actually solve or address it; fourth that initiatives
won’t introduce new problems; fifth that it is possible to overcome any obstacles that have been
identified; and sixth, stakeholders must agree to implement the change. We add a seventh: that
progress must be evaluated.

The literature reviewed in the first monograph of this series (Hindle, Braithwaite and Iedema,
2005) leaves no doubt as to the evidence for the scale of the problem. While there remain some
disagreements about the actual number of errors (Macdonald, Weiner and Hui, 2000; Leape,
2000) and the methods used to identify them (Vincent, 2003: Thomas and Petersen, 2003), it is
not feasible to deny that patient safety is a major concern over and above other technical and
procedural challenges to providing good care (Classen and Kilbridge, 2002). Although there is


variation in the incident rate depending on the study, it is generally agreed that some 10% of all
admissions are associated with an adverse event (Thomas, Studdert, Runciman, Webb, Sexton,
Wilson, Gibberd, Harrison and Brennan, 2000; Runciman, Webb, Helps, Thomas, Sexton,
Studdert and Brennan, 2000; Vincent, Neale, and Woloshynowych, 2001; Davis, Lay-Yee, Briant,
Ali, Scott and Schug, 2003; Schioler, Lipczak, Pedersen, Mogensen, Bech, Stockmarr, Svenning
and Frolich, 2001; Baker, Norton, Flintoft, Blais, Brown, Cox, Etchells, Ghali, Hebert, Majumdar,
O’Beirne, Palacios-Derflingher, Reid, Sheps and Tamblyn, 2004).

2.2 Tackling patient safety


The direction of the solutions to the problem, and agreement that the proposed solutions will
be more effective and will not introduce additional problems, is more difficult to determine.
As responses to patient safety proliferate it becomes more, rather than less, difficult to gain
consensus about what should be done, when by whom, and why (Braithwaite, Westbrook and
Iedema, 2005).

What has become evident in recent years is that the complexity of the patient safety problem
requires a comprehensive and concerted, longitudinal approach (Braithwaite, Travaglia,
Westbrook, Jorm, Hunter, Carroll, Iedema, Ekambareshwar, 2006). Current research points
to the need for a combination of approaches: organisational, technological, educational, and
cultural (Braithwaite, Westbrook, Travaglia, Iedema, Mallock, Long, Nugus, Forsyth, Jorm and
Pawsey, in press; Iedema, Jorm, Long, Braithwaite, Travaglia and Westbrook, 2006; Institute
of Medicine, 2001; Larson, 2002; Cohen, Kimmel, Benage, Hoang, Burroughs and Roth, 2004;
Amalberti, Aurory, Berwick and Barach, 2005; Institute of Medicine, 2000; Rosenthal and
Sutcliffe, 2002; Watcher, 2004) at four levels: systemic, organisational, team and individual
(Ferlie and Shortell, 2001). This is why the CEC and its programs and projects aiming at
improving quality and safety in multiple ways are so important.

The second monograph in this series (Hindle, Braithwaite, Travaglia and Iedema, 2006) provides
some insights into the obstacles involved in the implementation of patient safety programs. The
authors identified common features in health services that had experienced major breaches in
patient safety. These included: deficient quality monitoring processes; the dismissal of concerns
raised by health care providers, patients and families over long periods of time prior to major
patient safety incidents; the ignoring and abuse of active critics of systems or services; deficient
teamwork; and lack of involvement of patients and families as part of health care teams.

Various initiatives have been proposed to tackle patient safety. These include: system-wide
quality approaches (Institute of Medicine, 2000; Affonso and Doran, 2002; Ketring and White,
2002); non-punitive incident reporting structures (Barach and Small, 2000; Braithwaite, Travaglia,
Westbrook, Hunter, Carroll, Iedema, Ekambareshwar, 2006) which encourage active learning
from errors (Small and Barach, 2002); dedicated monitoring bodies (Institute of Medicine, 2000;
Dimond, 2002); the development of safety and reporting cultures (Stalhandske, Bagian and
Gosbee, 2002; Larson, 2002; Spath, 2001); effective leadership (Braithwaite, Finnegan, Graham,
Degeling, Hindle and Westbrook, 2004; Mycek, 2001; White and Ketring, 2001); teamwork
(Sprenger, 2001: Turnball, 2001; Mohr, Barach, Cravero, Blike, Godfrey, Batalden and Nelson,
2003; Firth-Cozens, 2001); and involving patients in the team (Robinson and Nash, 2000;
Vincent and Coulter, 2002). The CEC’s work [http: www.cec.health.nsw.gov.au/] is intended to
provide a system wide response to embrace these types of initiatives.
 Giving a voice to patient safety in New South Wales

These initiatives are supported by most expert commentators, and they are seen as
underpinning a belief in health professionals’ commitment to patient safety. Braithwaite et
al. (2005), for example, found in their evaluation of the NSW Safety Improvement Program
(SIP), that some participants had begun to change their work practices, had improved their
incident reporting practices, and felt that they were better able to address patient safety issues
(Braithwaite, Travaglia, Mallock, Iedema, Westbrook, Long, Nugus, Forsyth, Jorm and Pawsey,
2005; Braithwaite, Westbrook, Mallock, Travaglia, Iedema, 2006; Westbrook, Braithwaite,
Travaglia, Long, Jorm, Iedema, in press).

This literature provides significant insights into the strategies and approaches which are currently
being employed to reduce errors and improve safety. This phase has been referred to as the “end
of the beginning” (Watcher, 2004). The next era of patient safety has been labelled, a little less
prosaically, as the “hard phase”. It is hard, because it will ask “… health professionals to change not
only their traditional ways of thinking and doing but their images of themselves ….” (Schyve, 2006).
In other words, it will demand a significant culture change from all health professionals, and the
active involvement of health care organisations, policy-makers, educators and other stakeholders
(Mccarthy and Blumenthal, 2006).

2.3 Giving a voice to patient safety


In this monograph we sought to give a voice to the health professionals who have lived through
the (at times tumultuous) end of the beginning and who are currently faced with transition to the
hard phase. We gathered the views of nurses, doctors, pharmacists, allied health professionals,
academics and managers in 30 focus groups across NSW. In total 195 people added their voice to
the study. Some participants were recent graduates; most were senior clinical staff and executives.
Some of the focus groups came together as a single discipline; the majority was constituted in mixed
groups. We explored their experiences, sought their opinions about the causes of, and possible
solutions to, breakdowns in patient safety, and asked them what they thought it would take to
achieve the goal of reducing errors and improving safety for all patients.

In the monograph we report the major findings and key themes from our study: what were
participants’ biggest concerns, that is, what kept them awake at night? Had their concerns changed
in recent years? Were there any groups that they felt were at higher risk than others in the health
care system? What were participants’ experiences of medical errors? What is the health system
currently doing well and what needs to be improved? What key factors need to be addressed to
continue improvements? If they could do one thing to improve patient safety, what would it be? What
should be the major focus of the Clinical Excellence Commission? The participants provided frank
and honest responses to what were, at times, difficult questions. Most importantly they provided
valuable insights into the ways in which significant cultural change, leading to improved patient
safety, might be achieved.


3 Methods

3.1 Sample and procedure


Two sets of focus groups were conducted in order to sample views at different points in time.
The first set, of 25 groups, was carried out in August and December 2004 by the three authors
from CCGR. Participants were recruited through the Area Health Services (AHSs) in NSW.
Contact was made via Patient Safety Officers in each AHS, who helped distribute information
(flyers and emails) about the study and arrange suitable times and places for the groups. The
groups were conducted in three major cities in NSW (Sydney, Newcastle and Wollongong) and
in a number of locations, including hospitals, community health centres, offices, and in one case
a University. Participants were drawn from AHSs, a state-wide health service, and two state-
wide health advisory groups. A total of 171 individuals participated in the 2004 groups. Over two
years later the second set of five focus groups was conducted in order to gauge any changes
in concerns and perceptions of health professionals. This work was conducted in March 2007.
Contact was made via Clinical Governance Units in each AHS. Three AHSs and three state-wide
services responded. The AHSs included both metropolitan and rural locations. Participants were
drawn from a variety of hospital, community health and geographic locations in each service. A
total of 24 participants participated in the 2007 study.

In both sets of focus groups participants came from a range of discipline backgrounds,
metropolitan and rural AHSs, and had different levels of seniority and experience. This was
a convenience sample of academic clinicians, allied health workers (including pharmacists,
physiotherapists, occupational therapists and social workers), nurses (both hospital and
community health), doctors, managers, executives, policy-makers and patient safety and quality
officers. We actively sought out a sample which would represent the diversity of professions and
experience in the current NSW health workforce. Participants did not receive payment for their
attendance at the focus groups, but where appropriate, morning or afternoon tea was provided.

For reasons of confidentiality, individuals are not identified by name, organisation or AHS, in
either transcripts or this monograph. This requirement meets both ethics requirements and
expressed wishes of a number of participants. The studies were approved by UNSW’s Social
and Health Human Research Ethics Advisory Panel.
 Giving a voice to patient safety in New South Wales

3.2 Participants’ characteristics


A total of 195 participants attended 30 focus groups. Table 1 below provides details of the numbers
of participants in each group, their field of expertise and discipline backgrounds.

Table 1: Characteristics of focus groups

Focus No. of
Field of expertise Disciplines
group no. participants
1. Academics (health services research) Academics 6
2. Patient Safety and Quality Managers Mixed 9
3. Community Health Nursing Nursing 9
4. Senior Health Executives Mixed 5
5. Senior Health Executives Mixed 11
6. Nurse Unit Managers Nursing 5
7. Nurse Unit Managers Nursing 6
8. Allied Health Allied Health 7
9. Junior Medical Officers Medicine 14
10. Pathology Mixed 6
11. Infection Control Senior Nursing 3
12. Nursing Staff Senior Nursing 9
13. Nursing Staff Nursing 4
14. Quality Managers Mixed 2
15. Pharmacy Pharmacy 11
16. Pediatric Nursing Nursing 4
17. Allied Health Allied health 6
18. Pharmacy Pharmacy 12
19. Medical/Nursing Mixed 9
20. Allied Health Allied health 6
21. Allied Health Allied health 6
22. Nursing New Graduate Nurses 4
23. Nutrition Mixed 5
24. Senior Nursing Staff Senior Nursing 5
25. Senior Nursing Staff Nursing 7
Total from 2004 focus groups 171
26. Allied Health Allied Health 5
27. Managers Mixed 5
28. Nursing Nursing 5
29. Medical Practitioners Medicine 3
30. Patient Safety Managers Mixed 6
Total from 2007 focus groups 24
Total 195

We collected descriptive data on the samples. Table 2A provides a summary of the characteristics
of the 2004 participants who responded to the demographic questionnaire (n = 158) in Appendix 1.
Note that not all respondents answered all questions.


Table 2A: Demographic characteristics of the 2004 questionnaire respondents

Characteristics Participants

Female (n = 126) 79.8%


Gender (n = 158)
Male (n = 32) 20.2%

Age range: 22 – 66 years

Age (n = 135) Average age: 39 years

Median age: 39 years

Australia (n = 92) 67.1%

United Kingdom (n = 20) 14.3%

New Zealand (n = 4) 2.9%

South Africa (n = 3) 2.3 %

Bangladesh (n = 2) 1.5%

Czechoslovakia (n = 2) 1.5%

India (n = 2) 1.5%

Ireland (n = 2) 1.5%

Country of Birth* (n = 137) Finland (n = 1) 0.7%

Germany (n = 1) 0.7%

Guyana (n = 1) 0.7%

Hong Kong (n = 1) 0.7%

Malaysia (n = 1) 0.7%

Netherlands (n = 1) 0.7%

Poland (n = 1) 0.7%

United States of America (n = 1) 0.7%

Vietnam (n = 1) 0.7%

Yugoslavia (n = 1) 0.7%

Academic researcher (n = 6) 3.8%

Allied health (n = 30) 19.1%

Health services management (n = 13) 8.3%


Discipline (n = 157)
Medical practitioners (n = 18) 11.5%

Nurses (n = 69) 43.9%

Pharmacists (n = 21) 13.4%

Range of experience: 1 – 40 years

Average years of experience: 15.9 years


Years of experience (n = 139)
Median years of experience: 14 years

Mode for years of experience: 20 years


10 Giving a voice to patient safety in New South Wales

PhD (n = 4) 3.0%

Fellowships (n = 10) 7.5%

Masters degree (n = 40) 29.9%

Graduate diploma (n = 18) 13.4%

Graduate certificate (n = 2) 1.5%


Highest qualification (n = 134)
Undergraduate degree (n = 44) 32.9%

Diploma (n = 5) 3.7%

Certificate (n = 1) 0.7%

Non-degree nursing qualification (n = 9) 6.7%

TAFE certificate (n = 1) 0.7%

Manager (n = 70) 52.2%


Manager (n = 134)
Non manager (n = 64) 47.8%

*Names of countries as stated by participants

Table 2B provides a similar summary of the 2007 participants who responded to the demographic
questionnaire. Again, not all respondents answered all questions.

Table 2B: Demographic characteristics of the 2007 questionnaire respondents

Characteristics Participants

Female (n = 19) 79.2%


Gender (n = 24)
Male (n = 5) 20.8%

Age range: 32 - 62
Age (n = 13) Average age: 47
Median age: 47

Australia (n = 9) 69.2%
Country of Birth*
United Kingdom (n = 3) 23.1%
(n = 13)
Czech Republic (n = 1) 7.7%

Allied health (n = 1) 7.1%


Health services management (n = 2) 14.3%
Discipline (n = 14)
Medical practitioners (n = 3) 21.4%
Nurses (n = 8) 57.2%

Range of experience: 2 – 35 years


Years of experience Average years of experience: 21.6 years
(n = 13) Median years of experience: 14 years
Mode for years of experience: 26 years

PhD (n = 1) 7.2%
Fellowships (n = 3) 21.4%
Highest qualification
Masters degree (n = 5) 35.7%
(n = 14)
Undergraduate degree (n = 3) 21.4%
Non-degree nursing qualification (n = 2) 14.3%

Manager (n = 10) 76.9%


Manager (n = 13)
Non manager (n = 3) 23.1%
*Names of countries as stated by participants
11

Proportionally, health workers in this study were roughly equivalent to the Australian health
services workforce overall. As of 2005, 10.5% of the Australian health workforce were medical
practitioners, 53.6% were nurses, 6.9% were allied health workers and 2.6% were pharmacists
(Australian Institute of Health and Welfare, 2006). There is a small under-representation of
nurses and over-representation of allied health workers in our sample.

3.1 Focus group method and content


Focus group questions (Appendix 1) were developed via reviews of the patient safety literature
and work on international inquiries into patient safety previously undertaken (Hindle, Braithwaite
and Iedema, 2005; Hindle, Braithwaite, Travaglia and Iedema, 2006). The questions were piloted
with a small group of health professionals (nurses, doctors and allied health), minor modifications
made, and the results discarded.

Standard focus group techniques were used (Iedema and Braithwaite, 2004; Krueger and Casey,
2000; Morgan and Krueger, 1997; Puchta and Potter, 2004), although in a few of cases, the
small number of participants (eg, in focus groups 11 and 14) resulted in what would be better
described as a mini-focus group or in-depth interview. Researchers introduced themselves,
outlined the purpose and intent of the focus group and circulated ethics forms and the
demographic questionnaire (Appendix 2). Questions were open-ended to allow for wide ranging
discussion and to tease out a broad range of perspectives. Additional material came from short
written questions which were interspersed with the focus group discussion (Appendices 3 to 5).
Completion of the written questions was entirely voluntary, and in some cases participants chose
not to complete written questions, nor to submit their (unidentified) demographic details. This
was in accordance with the ethics requirements.

Groups typically ran from 1 to 2 hours. The groups were facilitated by at least one of three
researchers, with another present in most cases. All researchers have experience in conducting
focus groups.

3.2 Analysis of focus group data


Discussions were audiotaped and the tapes transcribed. The focus group transcripts were then
analysed using a formal content analysis procedure (Neuendorf, 2002; Miles and Huberman,
1994). Researchers read the transcripts and identified the key concepts and themes in each
transcript using an iterative, grounded theory approach (Glaser and Strauss, 1967). The themes
were hand coded for analysis via NVivo7, a qualitative data analysis package (Bazeley and
Richards, 2000).

Triangulation (Neuman, 2003; Mertens, 2005; see also Braithwaite, Westbrook, Mallock,
Travaglia, Iedema, 2006; Braithwaite, Westbrook, Travaglia, Iedema, Mallock, Long, Nugus,
Forsyth, Jorm, Pawsey, in press; Westbrook, Braithwaite, Travaglia, Long, Jorm, Iedema, in
press) was achieved using two methods. Firstly, the findings were reviewed by three researchers
with different discipline bases: organisational psychology, medical sociology and health services
research. Secondly, to confirm validity, the findings were compared against the extensive
reviews of the patient safety literature and international inquiries previously conducted by two of
the researchers. The overall findings are presented in the next section, organised to reflect the
flow and structure of the focus group questions.
12 Giving a voice to patient safety in New South Wales

4 Findings

In this section, we present focus group responses to eight key questions: What were participants’ biggest
concerns, that is, what kept them awake at night? Had their concerns changed in recent years? Were there
any groups that they felt were at higher risk than others in the health care system? What were participants’
experiences of medical errors? What is the health system currently doing well and what needs to be improved?
What key factors need to be addressed to continue improvements? If they could do one thing to improve
patient safety, what would it be? What should be the major focus of the Clinical Excellence Commission?

4.1 In terms of patient safety, what keeps you awake at night?


Yes, when things go wrong. If someone does a fall at home and you’ve actually been out to
see them, you instantly think ‘was it something I missed?’ You immediately take it on and think
‘was there a way I could have prevented it and have I done all I can?’ Even if they haven’t
already fallen, it’s just ‘have I done all that I can, have I covered everything for the client and for
myself?’ So it’s two things – for the client and for myself and the legalities. (Allied Health Focus
Group)

Health care professionals in each of the 2004 focus groups in this study reported some level of
anxiety about patient harm, medical errors or their contributing factors. For some professionals, the
experiences were direct: the anxiety they felt was as a result of an event they had either personally
been involved in, or had witnessed previously, even years before. Most focus groups, however,
concentrated on issues at the systems, organisation or team level.

The most common systems and organisational concerns identified by focus groups (n = 25) were:
time pressures (n = 9); workload (n = 9); expertise or skills of staff (n = 11); number of staff (n = 7);
education/supervision/support (n = 7); quality improvement (n = 3); and potential and preventable
errors (n = 2).

From our perspective, we’re only [a small hospital], so we have a lot of trouble getting our staff
actually trained … we’ve asked to be invited to other hospitals … so that we can learn from
that. We don’t get any information from the other hospitals in [our AHS] at all so that we can’t
go on the recommendations or look at how many near-misses they have and what they actually
do about it…. (Senior Health Executive Focus Group)

The most dominant systems concerns were issues of workload, time pressures, experience and
numbers of staff. Time pressures were seen as increasing as a direct result of reduction in the
number of experienced staff, which in turn, along with changing patient demographics, had resulted
in increased workloads. These factors were perceived as converging to reduce the level of patient
safety.

I think staffing is one of the problems, the fact the nurses are always so pushed, they are
having to look after so many patients. I think if there was more staff it would help. It would also
be good if there were more pharmacists around as well, because they don’t have time to go
through medication lists, find out what people came in on, and write lists for the patients when
they go home. Communicate with community pharmacists, things like that …. (Medical Focus
Group)
13

Staff inexperience was seen as problematic in three ways. Firstly there was a need to supervise
and support new staff more closely, an activity which took more experienced staff members away
from their other duties. Secondly, the lack of experience of junior staff was seen as contributing
to time pressures, as more experienced staff “… get through the work twice as fast and they
don’t miss things.” (Nurse Unit Manager). Agency and casual pool (n = 2) staff were seen as
contributing to time pressures because of the constant need to inform them about the hospital
or teams’ particular policies and procedures. Thirdly, in a small number of groups concern was
expressed about the ability or skills of staff to undertake the work required. Both experienced
and less experienced staff described potential and preventative errors as causing high levels of
anxiety, with one respondent still able to describe waking “… out of a sleep in a sweat thinking
‘oh my God’ ….” years after the event.

While quality improvement strategies were seen as a positive step forward, some questions
remained. These included: the need for standardisation and dissemination of quality and
safety approaches and procedures (which was raised by three groups) to stop “… every facility
reinvent[ing] the wheel as far as policy and protocols go…”; the question of how to increase
participation in quality improvement activities, particularly by doctors; and how to translated
policies and procedures “… down to floor level.”

At the “floor level” focus groups described issues including: communication, documentation and
feedback (n = 8); teamwork or lack thereof (n = 8); medications (n = 6); appropriate discharge
and or referral procedures (n = 6); falls (n = 5); equipment and environmental issues (n = 5);
and infections (n = 2). Communication, documentation and feedback were seen as impeding
patient safety in two competing ways. Lack of adequate communication and feedback was
seen as preventing improvements in quality and services. Conversely, trying to keep up with
documentation was seen by one group as impeding the time available to spend with patients.
Similarly, effective feedback was seen as a positive contributor to improvements in safety, but
one participant felt that “… there’s a lack of feedback to staff too, so that problems aren’t fixed in
a timely fashion.”

Communication was a recurring theme. The need was expressed for multidisciplinary teamwork,
which was particularly raised by nurses and allied health professionals. The most common
concern was the perceived difficulty of allied health, nurses and junior staff in having their
opinions considered and respected, in particular by medical staff. Appropriate discharge and
planning procedures was an offshoot of this concern. Here too, participants raised the issue of
patients being discharged before all professionals, but in particular allied health professionals,
were able to provide input into their ongoing care planning.

There is not a good system of communication. It is very much ad hoc sometimes. We


have many patients. One person says one thing and another person says something
else. Doctors will often walk in and suggest sending someone home. The patient is from
the country somewhere, so there is a lack of planning and lack of forethought in the
communication. In addition, how far do you push things? You do get to the point after so
many years, of being tired of it all – the ethical side of it and the legal side of things. You
sometimes feel that you are not doing as much as you can, but you know that the doctor
does not want to do that sort of thing, so you back off …. (Mixed Focus Group)

Medications were seen as a serious concern, both in relation to the prevention of errors and also
because of the potential hazards of multiple medications on factors such as falls. Of the range of
potential medical errors, it was medication errors and falls that were most often raised as specific
examples of patient safety concerns. A pharmacist said this:
14 Giving a voice to patient safety in New South Wales

It’s usually something I think I might not have done. That drug interaction because patients
have lots and lots of medication and sometimes you’re a bit too busy or too pushed to think of
everything and you think ‘gosh, I must check that tomorrow’ or sometimes you actually forget
to dispense something. You write it on the medication chart that you’re going to dispense
something and have it sent to the ward but you get distracted by someone asking you a
question or you’re talking to the patient and you forget to write it down on your transcription
sheet, so then it doesn’t get dispensed. So sometimes I wake up at night and think about that,
but not very often…. (Allied Health Focus Group)

There were other issues affecting individuals. In terms of staff, there were worries about
accountability (n = 4) and litigation (n = 2). In relation to patients, there were concerns about
patients’: ability to be discharged (n = 5); the acuity of their conditions (n = 4); and open disclosure
(n = 1).

The emphasis is so much on getting the beds free that I find a lot of people that are in much
longer than they should be, but there’s the other end with people who get discharged who are
medically okay, but they’re not necessarily safe. I had one last night, I was up with her and she
was in theatre … in her late 70s with a fractured wrist and she was discharged at nine o’clock
last night. She’d just got out of recovery at 4 o’clock yesterday afternoon. That is something
that happens a lot …. (Nursing Focus Group)

All participants who raised the issue of accountability spoke to its importance, in particular in
the light of the push for a no-blame approach. Accountability was seen to be needed both at an
individual and at a systems level. Litigation was raised as a concern in two groups. Nosocomial
infections were raised as problems by two groups.

Patients were the central focus of most groups’ responses to the question of what keeps them up
at night. However, most of the discussions were in relation to how organisational issues may affect
patient care and safety. Some additional matters were raised which highlight the role staff play in
actively advocating for patient safety, particularly patients with high needs.

It is important to note that although our line of questioning asked participants about their concerns,
people in three groups said that nothing kept them awake at night, that is, they felt that patients
were relatively safe in their organisation. An Allied Health Professional also offered the following
unprompted insight:

Having said that, things have definitely improved over the last five years, even the fact that
we are sitting here talking to you. We might not have been asked before. Even though these
are real issues … the fact that we have a system [where] we can report through and with, to
address some of these issues and that we do have a policy in place now … there are positives.
(Allied Health Focus Group)

The 2007 focus groups identified a very similar range of issues. The most common systems and
organisational concerns identified by focus groups were: workload (n = 6); expertise or skills of staff
(n = 5) especially junior staff; ability to provide timely and appropriate care (n = 3) e.g. “not having
enough time to provide what I feel is safe and effective care”; potential and preventable errors (n
= 3); competing state and organisational priorities and policies (n = 3); overall systems design and
provision (n = 2); access block (n = 1) and the ability to sustain patient safety strategies (n = 1).
Resources continue to remain an issue (n = 2).
15

There are so many competing things in terms of overseeing and management, for the
whole organisation, that its really hard sometimes to really push the patient safety issue,
sometimes you get drowned out by budgets and other things like that … you are concerned
that some things are not going to get done that could potentially lead to significant harm
in the future … it is improving and heading the right way, but it seems as though that
the resources don’t allow us to get to the really risky things right away. (Patient Safety
Managers’ Focus Group)

The impact of root cause analyses (RCAs) (n = 2) and the Incident Information Management
System (IIMS) (n = 2) were seen as a double edged sword. On one hand they assisted in the
identification of large numbers of errors and near misses. While this was seen as a positive
development overall, some participants said that given the workforce and resource issued
identified earlier, services were not able to address or prevent a significant percentage of the
errors identified.

We identify issues on RCAs, we get support and endorsement of executive level to act on
those things and many of them we find very hard to implement in the workplace, in terms
of time and resources, and then we get another incident when the same issue comes up…
(Management Focus Group).

At a service or ward level, focus groups were concerned about: communication and feedback,
including feedback from RCAs and other safety strategies (n = 7) and handover (n = 2); follow
up and follow through of patients (n = 2) including concerns caused by pressure to discharge
patients (n = 2). Specific error types that were identified by groups included medication errors (n
= 4) and falls (n = 2).

What keeps me awake at night is the void that you feel when you discharge patients …
are they going to receive the timely and appropriate follow up care that you would like? Is
it going to be sustained for long enough? Are they going to get the packages that you have
set up for them? (Allied Health Focus Group)

Staff turnover was considered a significant issue by one group, as were pressures on senior
staff. A common concern for both staff and patients was their overall safety and security,
particularly in the light of increasing violence (n = 2).

Anxieties about patients centred on higher levels of acuity and complexity (n = 5). A number of
new concerns appeared to focus on specific types of patients. These included: socially and or
geographically isolated patients (n = 3); rapidly deteriorating patients (n = 2); and people with
intellectual disabilities (n = 2).

4.2 Have your concerns about patient safety changed in recent years?
There is much more emphasis on the governance issues …. Everybody is much more
focussed on that - patient safety issues - and making sure that the systems are in place to
support us in reporting RIBS. We have had training on how to do RCAs and all those things
have improved over the last five years. (Nursing Focus Group)

Overall, the 2004 focus groups indicated that their concerns about patient safety had changed
in recent years, with most of the systems changes seen as positive. Increased focus on
governance (n = 4) and patient safety (n = 6) in general was seen as a positive move, along
with staff taking greater accountability (n = 3). The gradual acceptance of a no-blame systems
16 Giving a voice to patient safety in New South Wales

approach (n = 3) and incident reporting, reportable incident briefs (RIBs) and root cause analyses
(RCAs) (n = 3) were also seen as positive changes. It should be noted, however, that three groups
also raised concerns about incident reporting. These related to the use of incident reporting as
a reactive rather than proactive mechanism for patient safety and a perceived lack of feedback
from the process. More pragmatically, two focus groups commented on the improved use of risk
assessment tools.

There are high risk patients … always invariably on day one, they’ve got a needs assessment
right from day one. To get that [in the past] it would normally take days sorting these patients
out. (Medical Focus Group)

Several focus groups felt that safety had not improved significantly or that the “real” issues had not
been addressed (n = 6). Some focus groups raised increased workloads as a safety concern (n = 4)
along with the loss of senior staff (n = 2) and the lack of staff or adequately trained staff (n = 8), as
affecting safety. These concerns were often coupled with discussions about the increase in higher
acuity patients (n = 7) and shorter hospital stays (n = 2).

There’s going to be issues everywhere but we’re looking at health systems that started as little
systems, then technology and knowledge changed. So those systems had to incorporate the
new systems which provided the new technology but they’re not blending well. So the mergers
of all those systems have got little splinters all through them. Now you’ve got people training
through systems and they’re back-breaking workloads. Every three months I’m training new
residents. They get half an hour with me [to] tell them how to order safely. (Senior Nursing
Focus Group)

In relation to patients, a number of issues have emerged, most notably the rise of the “aware
patient” (n = 7). This was seen to have both positive and negative manifestations. From the positive
perspective, aware “… patients know now what their medications are, they know what they have to
do if there are any problems.” (Allied Health Focus Group). Patients were seen as being:

… a lot more savvy about their own rights now. I think that’s been a very big transition in the
last ten years, all that American focus on their rights and what they can and can’t do. I think that
creates an element of concern in terms of have we done all we can do to limit or lower the risk
of incidents…. (Nursing Focus Group).

Increased patient awareness was linked to the rise in litigation (n = 4) and negative media coverage
(n = 5). Increases in information technology, especially use of the internet, was identified as having
shaped patients’ expectations (n = 2).

I think also it’s the information age, there’s a lot more medical information easily available via
the internet and other sources, so the average consumer is much more aware; they can go
home from the doctor’s office and see if the information they’ve been given is correct, or if
something goes wrong with a relative in hospital they can straightaway get the information to
find out what’s going on, whereas in the past they couldn’t do that. (Senior Health Executive
Focus Group)

There was also a perception that patients and their families had become more demanding
(n = 2). Aggression, from patients and from other staff (n = 2), was seen as a significant and
troubling change.
17

I think there’s another way that our customer base has changed too, and that is I think that
issues to do with aggression and violence in the workplace are there now in a way they
were not even five years ago. It can be verbal and it can be physical, and that introduces a
whole new dimension of stress that causes horizontal problems in teams as well. (Senior
Health Executive Focus Group)

Responsibility for patient safety was seen much more than in the past as being the responsibility
of “everyone” (n = 10). Two groups specifically mentioned staff responsibility, and three groups
mentioned the need for patient, or patient and family, responsibility.

I think it’s everybody’s job and we all add to the picture. We all have a piece of the puzzle.
For me, a lot of it is around policy development and strategic planning but for the nursing
sister whom I supervise it is assuring that it actually comes off and they report if they think
something has happened, so I think it’s everybody’s job but once again I think you really
need that time to actually sit and discuss where we all put our pieces together and I don’t
think some people can actually start to think that broadly and widely. It’s not a criticism; I
think that’s just where they are at. (Senior Nursing Focus Group)

The responses from the 2007 participants closely mirrored those of the previous focus groups,
with a perception that commitment to improving patient safety had continued to increase in
recent years (n = 5). One participant described it as reaching “critical mass in terms of safety
awareness” (Management Focus Group). Risk assessment and clinical redesign were mentioned
by one group each as an example of significant improvements in recent years.

Changes in concerns in recent years were attributed to a combination of factors. These


matched those in the previous focus groups, and included: increased patient awareness (n = 2)
particularly as a result of the internet (n = 1); increased expectations from patients and families
(n = 1) including issues of litigation (n = 1) and increased complaints (n = 1) – neither of which
were necessarily seen as negative; increased patient acuity and demographic changes (n = 2)
“safety needs are reflecting changes in the client population”; and shorter stays in hospitals of
sicker patients (n = 1).

Staffing and workforce issues (n = 4) including fewer and more junior staff, a general lack of
resources (n = 2) continue to remain a concern. Increasing administrative demands led one
participant to comment “… I could spend one and a half times my working life in front of a computer.”

The more recent focus groups in effect reflected on the maturing of safety improvement
strategies. These include a focus on the sustainability and transfer of quality and safety
improvement programs and projects (n = 3) and integration of a wide variety of projects and
priorities (n = 1). Incident reporting (n = 3) and RCAs (n = 2) were seen as contributing to a
positive change. Although participants openly acknowledged that these strategies contributed
to the identification, reporting and assessment of errors, they also raised concerns about: the
system’s capacity to respond to the causes identified; the focus on RCAs to the perceived
exclusion of other modes of analysis; and the lack of engagement of clinicians, particularly senior
clinicians and doctors, in these processes (n = 2):

I think there has been a cultural change, particularly with nursing staff, I think a lot of
this has been driven by nursing staff who generate the [IIMS] reports, whereas I am not
sure the cultural change is there with the medical staff yet … the issue is more in focus
… but the problem I have is getting … senior clinicians to serve on RCAs because they
don’t understand what it’s all about – at that level the message hasn’t gotten through yet.
(Medical Focus Group)
18 Giving a voice to patient safety in New South Wales

4.3 Do you think there are people or groups who are at higher risk (than
others) in the health system?
The 2004 focus group participants mentioned specific population group categories as being at
higher risk than others in the health system. Most common were the elderly (n = 17), followed by
people from non English speaking backgrounds (n = 13), people with mental illnesses (n = 10),
young people and children (n = 4), Aboriginal and Torres Straight Islanders (n = 3) and patients with
disabilities (n = 2). Elderly people were seen as being at risk as a result of a combination of frailty,
increased co-morbidity including cognitive impairments and dementia, and organisational difficulties
in providing adequate care.

Thinking about the frail aged, we don’t even have the appropriate physical environment for
them a lot of the time. We don’t have dementia-specific accommodation with secure units; we
don’t have the physical environment to deal with [elderly] patients. We need to look at more
outside the box stuff, padding floors, pressure-sensitive alarms, those sorts of things. (Senior
Nursing Focus Group)

One focus group also identified the issue of attitudes towards elderly people as a cause of higher
risk. As a Senior Executive put it:

I think there is a need for education, refocusing, particularly, there are growing numbers of
elderly people going into the public hospital system and they call them bed blockers which I
think is a dreadful term. It’s no wonder people develop an attitude that we shouldn’t be looking
after them, they shouldn’t be here…. (Senior Health Executive Focus Group)

People from non English speaking backgrounds were identified as being at risk because of lack of
ability to communicate, lack of family members and difficulties in accessing interpreters and support
workers. These last three issues were also said to apply to Aboriginal and Torres Straight Islanders.

The second most common group acknowledged as being at risk were patients experiencing various
forms of disadvantage. These included: isolated patients and those without family or support
systems (n = 9); patients from lower socio-economic backgrounds (n = 6); patients who live in
locationally disadvantaged areas (n = 3); patients who are illiterate or can’t communicate (n = 3);
patients experiencing domestic violence (n = 2); and the homeless (n = 1).

A patient without an advocate, whether that be a nurse or relative as an advocate, I think


that patient is at risk. My dad was in hospital last year and I wouldn’t leave his bed, I wanted
to double-check everything that went through, everything he received. Anyone without an
advocate I think is at risk. (Senior Nursing Focus Group)

Locational disadvantage was seen as stemming from three factors. Firstly, rural patients had
to either travel or be transported long distances for adequate treatment. Secondly, there was a
perception that services in locationally disadvantaged areas had fewer resources, and that these
were stretched by the complexity of social and health problems in these areas. Thirdly, there was
a sense that areas of high need were conversely, the least likely to attract highly qualified health
professionals they required.

Patients with co-morbidities (n = 3), cognitive impairment (n = 3), those who were malnourished (n
= 2), obese patients (n = 2), patients with dual diagnoses (n = 1), and patients with drug and alcohol
problems (n = 1), were also identified as being at risk. So too were patients who were bedridden
(and at particular risk of pressure sores), those who were post surgery, and those who had been
discharged early (n = 1 in each category).
19

In terms of malnutrition they say that up to 40 percent of adults and 60 percent of the elderly
admitted to hospital are malnourished and they lose weight in hospital and then go home
malnourished. Data in Australia and around the world has shown that, and basically those
patients are at an increased risk of infection, mortality in general, they’re weaker, not able to do
their physio, so there are all those other issues as well. And up until recently there has been no
community [nutritionist] positions, so basically they go home and they’ve got nothing and some
of the oldies get even more malnourished at home. (Allied Health Focus Group)

Staff were identified as being at risk by three focus groups, specifically in relation to aggression
(n = 3), burnout (n = 1), shiftwork (n = 1), tiredness (n = 1) and workload (n = 1). Staff who
were mentioned as being at highest risk were casual staff (n = 1) and new graduates (n = 2).
Aggression towards and between staff was identified as a significant risk factor. A small number
of examples provided included verbal and physical abuse from patients and family members.

Casual staff and trainees were seen as being at particular risk when they lacked adequate
support and supervision from senior staff. They were also seen as being at higher risk of making
an error. Participants in one focus group argued this way:

Being the casual that didn’t want to work on that ward and got put there because they were
so desperate and were out of their depth. I think those people are really tightrope walking a
lot of the time. (Senior Nursing Focus Group)

Amidst the discussion of risk there was also recognition of the way in which health services were
being delivered effectively to many groups. Although this question focussed on the issues of risk
and vulnerability, this is important to note, as one group did:

Yes, there are many needs being met. The Department of Health [statistics] show that there are
millions of patient encounters every year and there is a lot of good care delivered. With patient
safety, one of the problems with it is it tends to focus on the negatives, not the positives. A lot
of people get their complex birth delivered; their cancer treated, whatever, so we shouldn’t lose
sight of that. There is a lot of good care being delivered. (Academic Focus Group)

A similar range of individuals and groups was identified by the 2007 focus groups. Those
identified as being at higher risk included: the elderly (n = 5): people with mental health
difficulties (n = 3) with a special mention of youth (n = 2); young children (n = 3); patients with
high acuity (n = 3) and co-morbidities (n = 2); patients with communication difficulties (n =
5), including people from non English speaking background (n = 2) and those with general
communication problems (n = 3); people without family supports or advocates (n = 2); homeless
people (n = 2); people in emergency departments (n = 2); people undergoing surgery or in ICUs
(n = 2); and rural patients or patients who had long distances to travel to access care (n = 2).

Aboriginal and Torres Straight Islander patients were identified as a group at particular risk of
errors of omission, that is, errors as a result of delayed or incomplete treatment. As one focus
group member noted:

That’s the crying shame of it all, we’ve got some really excellent Aboriginal Health Workers
that can engage that population and with some pretty simple interventions early on,
particularly in renal and diabetes you can save a whole heap of morbidity and mortality
down the track … its just that one person … the Aboriginal Health Worker that coaxes them
into treatment or prevention … (Medical Focus Group).
20 Giving a voice to patient safety in New South Wales

As with the previous question, the second round focus groups identified some similar and some new
issues. These latter included: people with intellectual disabilities and communication impairments
(n = 3); rapidly deteriorating patients (n = 2); and patients being physically transferred, including
prisoners (n = 2). Two groups spoke generally of the “socially vulnerable” and patients who were
seen as being “less desirable” (in society) as being at particular risk.

There was less mention of staff as being at risk, although when they were mentioned, aggression and
violence were still the number one concerns (n = 2). Night staff, frontline staff and staff in small rural
hospitals were identified by one group each. Newer graduates, particularly those in their first year out,
were also identified as being at particular risk, as were staff who were not coping with the rate of change:

There are a certain number of very good staff … [who] and I see as we go through masses
of change which we have to do in a whole range of areas with the restructure, with a clinical
emphasis, clinical structures – whatever, we are all getting reformed and restructured all the
time and we do have some very good staff who just don’t seem to go with the change or have
change burnout … I think that is a risk area. (Management Focus Group)

4.4 Can you tell me about the last incident that you observed or heard about
that caused harm to a patient or prolonged their care?
Focus group participants’ oral examples of adverse events were categorised according to a schema
developed by the researchers from the Leape, Lawthers, Brennan and Johnson (1993) taxonomy of
common errors and the checklist for RCA teams developed by NSW Health and the Institute for Clinical
Excellence (ICE) (NSW Department of Health, 2004). Each example was given one major classification
(although most had a number of contributing factors) and was only coded once for each group
(irrespective of the number of participants who mentioned the same example). More than one example
was possible in each group. The results from the 2004 focus groups are presented in Table 3 below.

Table 3: Types of errors described in the 2004 focus groups

Type of error Example of error type

Diagnostic

A gentleman who has about 20 pressure areas because he


wasn’t picked up by his GP ... and now he is like a one and
Error or delay in diagnosis (n = 2) a half hour visit, and a huge drain on the service because
of something that could have been prevented. (Community
Nursing Focus Group)

Failure to employ indicated tests No examples of this error type were recorded in the focus groups

No examples of this error type were recorded in the focus


Use of outmoded tests or therapy
groups

This fellow, in those three to four weeks deteriorated. If you


looked at his albumin it was down from 25 to 16 – a massive
decrease – yet when the dietician intervened from day one
Failure to act on results of they were completely ignored, until they got the stage where
monitoring or testing (n = 1) I … had to get the doctor to address the case of this person
being malnourished. This person was not going to recover
from pneumonia if they were starving to death…. (Nutrition
Focus Group)
21

Type of error Example of error type

Treatment

The one that really sticks in my mind is … a patient with a


new trachie [tracheotomy] and there was a problem with the
new trachie but it was still functioning. The registrar who was
Error in the performance of an
on decided that he’d change it, and all the nursing staff were
operation, procedure or test (n = 9)
saying ‘no, no, no don’t change it, you won’t get another one
back in’. He couldn’t get one back in, and he couldn’t ventilate
the patient and the patient nearly died. (Nutrition Focus Group)

Error in administering the treatment No examples of this error type were recorded in the focus groups

It’s how it’s handled. The one medication error that I know I
made, I reported it. I made the mistake, as the manager of
Error in the dose or method of using the unit I need to be able to explain to my staff and say it can
a drug (n = 16) happen to you, learn from my error and let’s go through this
process, and if I am using myself as an example, fair enough.
(Senior Health Executive Focus Group)

I followed the notes for a few weeks and I saw this woman
deteriorate with an obvious aspiration pneumonia. She was
Avoidable delay in treatment or in
coughing, coughing, and steadily deteriorating. She did not
responding to an abnormal test (n = 4)
die, but that was because the nursing staff refused to follow
[orders]. (Allied Health Focus Group)

Inappropriate (not indicated care) No examples of this error type were recorded in the focus groups

Preventative

I had one [new mother] who the night the milk came the
Failure to provide prophylactic midwife said ‘I’ll take the baby out all night’ and the mother
treatment (n = 3) didn’t express breast milk and ended up with pathological
engorgement…. (Nursing Focus Group)

It was a patient who had a peg put in. He had it put in as a day
patient and he was on his own at home. He was given nothing to
Inadequate monitoring or follow-up
go home with, no syringe and no analgesia. He went home and
of treatment (n = 2)
was back in Casualty next day because he had not idea what to
do. He had no information at all. (Medical Focus Group)

Other

Something that could have caused a horrible problem was


a foetus and placenta we were sent from Casualty recently
that we were just told to do a histo on the body. The foetus
in question was recognisably human and I stopped and I
Failure of communication * (n = 6) thought, ‘hang on, they might want to bury [the body] or have
pictures or something like that’ so [I waited] and the social
worker got back to me and said ‘no, absolutely not, they don’t
want anything done to it, they want [the body] back to bury.’
(Pathology Focus Group)

There was a breakdown of the radiology system here because


our [machine] broke down earlier this year and it still hasn’t
been repaired or replaced and every time we have to do a
Equipment failure * (n = 1)
[specific procedure] it’s very difficult. We have to drive the
specimen to the nearest lab two hours away and back, and
there is a delay.... (Pathology Focus Group)
22 Giving a voice to patient safety in New South Wales

Type of error Example of error type

It was a clear case of someone who was thinking ‘I have my


own patients. I can’t deal with this’. This poor [patient] was
obviously being ignored and she was so incredibly distressed
Work environment/scheduling * (n = 1) and embarrassed. I thought ‘This is a bad day when nurses
stop caring and think ‘I can’t deal with this’ and walk away,
without referring a situation like that to the nurse’s station.
(Nursing Focus Group)

She felt that with this cardiac arrest, firstly, that some people
were not taking any notice of the fact that there was an
Knowledge, skills and competence arrest and secondly, the staff members on the ward ignored
(training) « (n = 3) the fact that there were junior staff members surrounding
this bed and struggling with what they had to do. (Senior
Nursing Focus Group)

We had a patient who forgot to take their medication and we


found out two weeks later that they hadn’t been taking the
Patient factors « (n = 4) oral chemotherapy agent they were supposed to be taking,
so we notified the consultant and it prolonged their treatment.
(Nursing Focus Group)

A patient came in and was having a massive hematemesis and


bleed. We have an emergency blood supply here 24 hours a
day and the medical staff and the ED staff did not know about
the emergency blood supply – they rang through to our tertiary
facility to get the blood which took another three hours. The
Policies, procedures and guidelines
patient’s blood pressure was bottoming out. The patient did
« (n = 2)
survive but they were lucky. I checked the blood fridge and
the records and there was an adequate supply of blood in
the fridge and no one knew about it and no one asked about
it. Madly, the same incident occurred a week later…. (Senior
Nursing Focus Group)

I had a patient came in, she was very old and extremely frail
with end stage renal disease and she had mild dementia. She
came to us with very mild [illness]… and she went to a bed that
was quite higher than she was used to at home and she got
out of bed to go to the toilet and sustained a head injury and
Safety mechanisms « (n = 7)
that was enough to set her off and she wasn’t quite her normal
self. The very next night she did exactly the same thing,
and another head injury. The next day she had a subdural
haemorrhage and died [a couple] of days later…. (Medical
Focus Group)

Other systems failure No examples of this error type were recorded in the focus groups

* Common to both taxonomies


« From NSW Health Checklist

Medication errors appear most frequently as the most recent adverse event observed (n =
16), followed by error in the performance of an operation, procedure or test (n = 9) and safety
mechanisms (n = 7). In the context of this report, the safety mechanisms category was used to code
falls, where no other contributing factor (eg confusion due to medication) was identified.
23

Examples of medication errors included cases of omission and commission, that is, both where
the wrong medication was given, and where the correct medication was not provided or delayed
or withheld:

… there’s a lot around warfarin management as well, probably a lot of medical errors and
omissions with that sort of thing, the managing of warfarin and complications at home,
taking it themselves. I don’t know how it’s managed in the community…. (Nursing Focus
Group)

As well as providing an illustration of medication errors, this example also highlights broader
issues of patient safety. These include patient education and the potential for longer term errors
once the patient has been discharged.

A small number (n = 5) of errors was not identified by focus groups in their discussions. This
included failure to employ indicated tests and use of outmoded tests or therapy, errors in
administering treatments, inappropriate care and other systems failures.

The adverse events identified in 2007 highlight a small range of persistent problems. Error in
performance of an operation, procedure or test (including wrong site surgery) was witnessed by
four groups.

ICU patient received dialysis where the machine was not set up properly - so they arrested,
and they wouldn’t have if the machine was right. (Allied Health Focus Group)

Three groups identified communication failures and a further three “other systems failures”
including two which resulted in completed suicides. Two groups each identified error in the dose
or method or using a drug, failure to act on the results of monitoring or testing, and in avoidable
delay in treatment or in responding to abnormal test.

A double of anti-coagulant effectively and they ended up in ICU – and nearly didn’t make it
and that was very serious. (Allied Health Focus Group)

Groups also gave examples of a range of other errors. These included: error or delay in
diagnosis; inappropriate (not indicated) care; failure to provide prophylactic treatment; work
environment/scheduling; knowledge skills and competence; and failure of safety mechanisms.

An elderly patient with dementia was sent to radiology for an x-ray with a wardsman, but
when they got there the wardsman pointed out … to the radiographer that the patient
appeared … very ill. The radiographer sent them to the ward, but by the time they got there,
the patient was dead. (Medical Focus Group)

As in 2004, a small number of errors was not identified by the 2007 focus groups. This included
failure to employ indicated tests and use of outmoded tests or therapy, equipment failure, patient
factors and policies, procedures and guidelines.

Focus group participants were provided with a handout (Appendix 3) asking about their
perceptions of rates of adverse events in their institutions. A range of staff had experienced
adverse events.

We also asked about minor events. In 2004 medication errors represented the largest category
of minor adverse events identified in the questionnaire. Safety mechanisms (including falls with
no major injuries) ranked second. In 2007 medication errors and falls were equal first.
24 Giving a voice to patient safety in New South Wales

In 2004, failure of communication appears third. Examples of minor errors in administering


treatments were provided along with one example of inappropriate care. Unlike in the focus groups,
no examples of failure to act on the results of monitoring or testing was provided. Nor was lack of
knowledge, skills or competence, possibly because these categories could potentially be seen as
a major error. In 2007 there were equal examples of wrong procedures, poor clinical management,
infections and failure of safety mechanisms (one incident each).

Participants were asked for examples of major adverse events. A total of 114 responses was
received for this question in 2004. A number of participants (n = 5) mentioned Severity Assessment
Code (SAC) definitions and another (n = 5) listed “death” or “injury”. The kinds of major adverse
events perceived included inadequate monitoring or follow-up of treatment, error in the dose or
method of using a drug and error in the performance of an operation, procedure or test.

The examples of major adverse events provide a different profile to those of minor events and those
discussed in focus groups. More examples were given in the: safety mechanisms category; cases of
inadequate monitoring or follow-up; and errors in clinician performance. Conversely, fewer examples
of medication errors were provided.

In 2007, 13 responses were received. Major events included: patient deaths from a variety of
preventable causes (n = 4) including falls; attempted self harm and suicides (n = 3); errors in
the performance of procedures (n = 4) including wrong site and wrong patients. One participant
identified medication errors and another, staff members being threatened by violence.

The final survey question asked participants to estimate the occurrence of medical errors in their
facility. In 2004, on average, 66.7% of participants thought medical errors occurred more frequently
than monthly in their institution. Only 21% thought they occurred rarely or not at all. Failure of
communication was the most frequent error identified by participants (81.6% said it occurred on a
daily or weekly basis). This was followed by errors in the administration of drugs (59.8% said on a
daily or weekly basis). Participants thought these errors occurred on a daily or weekly time scale:
other systems errors (57.7%); avoidable delays in treatment or response (56.6%); with 54.2% of
participants identifying errors or delays in diagnosis; and failures to employ indicated tests (53.4%).

On average, only 48.8% of participants in the 2007 focus groups thought that medical errors
occurred more frequently than monthly in their institution (a decrease of 17.9%). Error in the dose
of methods of using a drug was the most frequent error identified by participants (58.3% said it
occurred on a daily or weekly basis). This was followed by errors in communication (41.7% said on
a daily or weekly basis). Errors which were equally thought to occur on a daily or weekly basis by
participants (33.3%) included: failure to employ indicated test; failure to act on results of monitoring
or testing; errors in administering of treatments; and errors in performance of procedures.

4.5 What are we doing well in relation to patient safety?


We turn to the fifth study question. Here we changed the emphasis, and asked what sorts of things
were going well. One response from a 2004 focus group was as follows:

I think we are definitely reporting patient incidents well. We’re definitely reviewing. Not just
severe incidents, but incidents that we think are important for whatever reason. I think we
have a culture of honesty. I know from my interviews with staff that they are very honest, the
information they tell me, I think that’s very healthy. (Nursing Focus Group)
25

Patient safety was considered to have improved significantly in recent years as a result of
changes to the system, and improved organisational and professional cultures. Overall, the focus
on patient safety and the shift to a systems approach (n = 7) was acknowledged as a significant
step forward in safety, as was incident reporting (n = 5) and a move towards a proactive and
preventative approach to safety (n = 3). The conceptual move from a “blame and shame”
through to a no blame or just blame approach was affirmed as a good development by three
groups. Good care overall was cited by one group.

I think it’s good to have something that will be state-wide, so there’ll be more sharing of
information across the board, so the idea is that we’ll be able to catch something that’s only
happening a couple of times a year in each hospital, but as a whole is happening a lot, so it
will be quicker to put things in place to prevent it happening again. (Nursing Focus Group)

Improvements in various forms of communication were mentioned by a number of groups.


Examples included improvements in: gaining consent from patients (n = 2); collaboration
between groups (n = 2); sharing information (n = 1); talking to patients (n = 1); risk assessments
(n = 1); and feedback (n = 1).

The collaboration with the dieticians and the nurses has again come to the forefront. We are
talking about things, like food charts and understanding the significance of it, rather than
thinking it is another piece of paper that we have to fill out. The dieticians and nurses are
talking to each other and getting the doctors on board. The doctors are listening to what
everybody is saying and doing it, rather than one group dominating it all. There is more
collaboration now…. (Mixed Focus Group)

A number of groups mentioned particular areas where they felt health services were doing
especially well in terms of safety. These included: infection control (n = 2); aged care
rehabilitation and risk assessments (n = 2); education and training on safety issues (n = 2);
improvements in equipment and technology (n = 2); and the employment of Enrolled Nurses (n =
1). The introduction of Patient Safety Officers was also seen as a constructive step (n = 1).

Changes to some aspects of professional and organisational culture were also believed to be
promising. A commitment to, and support of multidisciplinarity (n = 6) was considered a very
positive development, as was the willingness to acknowledge, take accountability for, and learn
from, mistakes (n = 5) and openness, including open disclosure (n = 5).

I think the focus on patient safety is great and it’s very topical at the moment … and the
openness, while it’s still not perfect, it is improving. It’s no longer the sacred domain of the
doctors to be just in the M&M … the doors are slowly opening to allow the multi-disciplinary
teams to participate … people want to be learning; they want to talk about the mistakes that
occur and learn from [them] …. (Nursing Focus Group)

The 2007 focus groups identified a range of strategies, activities and approaches which were
contributing to positive improvements in patient safety at a variety of levels. Clinical governance,
safety champions and more effective responses to patient complaints were each identified by
one group.

The Clinical Governance Unit [in this service] has made a huge difference to the working life
of managers and nurses and patients … having a functioning clinical governance unit, it’s
taken an awful lot of pressure away from patients who were making complaints, and who
[had in the past] not been taken seriously … forcing NUMS and other managers to take the
complaints seriously (Nursing Focus Group).
26 Giving a voice to patient safety in New South Wales

Macro level changes included acceptance of incident reporting (n = 6); the no-blame approach (n
= 4) and open disclosure (n = 2). At a meso level improvements included a range of nominated
programs, such as TASC, access block, patient flow, falls, medication errors, pressure areas, clinical
redesign and clinical quality. These were seen both as effective strategies in and of themselves, and
as part of the general move towards reflective practice and learning from errors (n = 4).

In the last five years we have come a long way with both the reporting of incidents and the way
we handle them, which is extremely important, the no-blame [approach] which has taken place
in the last five years or so has allowed people to openly discuss when accidents do happen …
it’s led to a lot more learning. (Management Focus Group)

While incident reporting and RCAs (n = 2) were seen as effective overall, several groups
questioned the time and method taken to input incident data, particularly for senior clinical staff (n
= 2). A number of participants also identified problems with sustaining and embedding safety and
quality strategies either once project funding ran out, or through general lack of resources (n = 2).
Unlike the responses in other questions, which identified the difficulty in gaining senior clinicians’
involvement, a participant in one group felt that things were improving:

One thing I can see that is changing slowly but positively is the engagement of senior clinicians,
in terms of being a bit more accountable for the patient safety agenda, rather than seeing it is
a something they could discuss behind closed doors in M&Ms [Morbidity and Mortality reviews]
and leave the systems part of it to the organisation as they weren’t particularly interested, we’ve
really pushed them and ensured they are advised of every issue in their overarching stream
and reporting monthly to them on the implementations and recommendations and making sure
they are around the table. (Patient Safety Manager)

Participants were asked to describe briefly their organisations’ responses to the last adverse event
they had witnessed. Table 4 presents the responses from the 2004 focus groups.

Table 4: Participants’ views in 2004 of the last adverse event they observed

Types of responses to adverse events (n = 101)

Systems responses

Reportable Incident Brief submitted (n = 5)

Root Cause Analysis commenced (n = 10)

Incident report submitted (IIMS) (n = 11)

Organisational/team responses

Investigation (n = 6)

Review and development of education (n = 7)

File or documentation review (n = 1)

Risk assessment (n = 2)

Review and development of policies and guidelines (n = 5)

Review of systems (n = 1)

Change of practice (n = 4)

Review and or change to treatment or equipment (n = 7)

Identification and implementation strategy to prevent future re-occurrence (n = 6)


27

Types of responses to adverse events (n = 101)

Referred to Patient Safety or Quality Manager or Unit (n = 4)

Presented to Mortality and Morbidity Review (M&M) (n = 2)

Discussion at clinical review or safety meeting (n = 3)

Feedback to facility or team (n = 2)

Identification of strategy to support staff (n = 2)

Requested support from colleague or related professionals (ambulance, police) (n = 3)

Individual responses

Discussion with involved parties (staff, General Practitioners) (n = 2)

Discussion with involved parties (patients, carers or families) (n = 3)

Positive response from senior management (n = 3)

Negative response from senior management (n = 1)

Other

No support, response or feedback (n = 11)

Participants’ responses to adverse events can be seen as dividing along systems, organisation
and individual lines. At a systems level, the introduction of various forms of error reporting and
analysis is evident in participants’ responses. At an organisational level a range of investigations
and reviews are undertaken. As well as reactive approaches, proactive changes in practice,
treatment, equipment, policies, and education were identified (n = 23). Some 11 participants
mentioned that they had received no support or feedback in relation to past errors.

The 2007 focus groups recorded similar types of responses. The most common responses were:
IIMS report submitted (n = 4); discussion with involved parties - staff (n = 5) and patients and
their families (n = 3); investigations (n = 3); RCAs; review and development of education; review
and development of policies and guidelines; and referral to Patient Safety or Quality Manager
(each n = 2). Other individual responses included: RIB submitted; review of system; change of
practice; review and or change to treatment or equipment; identification and implementation of
strategy to prevent future re-occurrence; and SAC rating given.

Participants were asked to rate their service’s response to the last adverse event (Table 5).
Almost 100 participants responded in 2004. They were provided with three possible measures:
effective, efficient and whether they felt the action was ethical. While most participants felt that
their services’ response to the last adverse event was effective, efficient and ethical, a notable
minority did not.

Table 5: Participants’ 2004 rating of services’ response to the last adverse event encountered

Evaluation of responses to adverse events

The response was: Yes No

Effective (n = 96) 66 (68.8%) 30 (31.2%)

Efficient (n = 98) 62 (63.3%) 36 (36.7%)

Ethical (n = 95) 70 (73.7%) 25 (26.3%)


28 Giving a voice to patient safety in New South Wales

A total of 12 responses was received in 2007. Of these, 83.3% thought their services’ response was
effective, 83.3% thought they were efficient and 100% though they were ethical.

There were three final questions in the questionnaire. The first asked participants to whom they
go in the case of an adverse event (Table 6). People had clear views on to whom they wanted to
go for assistance or as a first point of contact in case of an adverse event. Participants were then
asked if they felt they had the authority they needed to get action about their concerns. A total
of 119 participants responded. Of these, 97 (81.5%) said that they felt they had the authority to
get the action they needed, while 22 (18.5%) said they felt they did not. The final question asked
participants to identify the likely cause of the next adverse event in their facility.

Table 6: Participants’ 2004 views on their point of contact for adverse events

Who do/would you go to when an adverse event happens (within your facility/service)? (n = 205)

Area manager (n = 1)

Executive Director or Facility Manager (n = 6)

Director of Service (n = 19)

Head of Department, Team Leader or Unit Manager (n = 17)

Patient Safety or Quality or OHS Manager (n = 14)2004

Governance or Quality or Service Improvement Unit (n = 6)

Appropriate internal Committee (e.g. Adverse Drug Effects Committee) (n = 2)

Immediate supervisor or manager (n = 55)

Medical Consultant, Officer or Team (n = 19)

NUM or CNC or CNE (n = 23)

Patient representative (internal to organisation) (n = 2)

Colleagues or peers (n = 8)

Friend/someone trustworthy (n = 2)

Staff (n = 5)

Someone outside facility (n = 1)

Complete RIB and or Incident Report (IIMS) (n = 15)

Myself (n = 3)

No-one (n = 1)

Don’t know (n = 1)

Other (n = 5) (include Legal Liability Officer, Counsellor, Employee Assistance Program)

In 2004, participants overwhelmingly said that they would go to their immediate supervisor or
manager in the first instance after encountering an adverse event, or to their Head of Department
or Team Leader (n = 72). Fewer would go directly to their Patient Safety or Quality Manager or Unit
(n = 20), although 15 participants mentioned that in the first instance they would fill out an incident
form. Overall, of the 205 responses (more than one response was possible for each participant),
70.4% mentioned going directly to management of some kind, while 4.3% mentioned speaking to
colleagues, friends or peers. The same general pattern held in 2007. Participants said they would
go to their own, or to the line manager of the individual involved, first. Two participants said that they
would make an incident report in IIMS at the same time.
29

Participants suggested a range of likely causes for the next adverse event in their facility. They
are closely mapped to participants’ perceptions of current causes of errors. The 2004 results are
presented in Table 7 below. More than one response was possible for each participant.

Table 7: Participants’ 2004 views on the possible causes of future adverse events

Potential causes of future adverse events (n = 181)

Systems

Increasing cost of medical treatment putting pressure on ED (n = 1)

Organisational

Access issues (n = 2)

Workload and staff – patient ratios (n = 13)

Clinical and work environment (n = 3)

Staff shortages (n = 23)

Skill mix (n = 7)

Time (n = 10), including time to identify source of potential errors

Culture of organisation (n = 1)

Education (n = 5)

Resources and equipment (n = 10)

Lack of services (n = 2)

Communication: inadequate systems (n = 3)

Lack of documentation or access to documentation (n = 3)

Lack of communication between managers and professionals (n = 1)

Team and individual staff members

Attitudes, lack of engagement with patients (n = 5)

Staff inexperience (n = 9)

Poor planning, especially discharge planning (n = 5)

Communication breakdowns and gaps, including lack of referrals (n = 22)

Communication: handovers (n = 1)

Communication: written (n = 2)

Lack of communication between professionals and teams (n = 3)

Not following guidelines, or conflicting policies (n = 2)

Continuity of care (n = 3)

Staff stress and low morale (n = 5)

Supervision issues (n = 1)

Individual (patient)

Patient characteristics (n = 5) including co-morbidities, isolation

Lack of support once at home (n = 4)

Non-compliant patients (n = 1)

Types of errors
30 Giving a voice to patient safety in New South Wales

Potential causes of future adverse events (n = 181)

Medication errors (n = 17)

Falls (n = 8)

Pathology error (n = 1)

Aspiration (n = 1)

Other

No idea (n = 1)

Litigation (n = 1)

Once again, responses can be mapped to broad systems categories. Responses to this question
reflect participants’ responses to the question of frequency of errors: across the board, failure of
communication (in its various forms) is identified as the number one contributor to errors (19.3%),
followed closely by workforce issues such as staffing shortages (12.7%), skills (3.9%) and
experience (5.0%) of existing staff, and workload (7.2%).

The 2007 responses (n = 18) showed a similar pattern, although medical errors (22.2%) rather
than communication failures (16.7%) was perceived as the likeliest cause of future events. Other
potential causes included: falls; workforce issues (including increased workloads and isolated
workers); failure to react in time or failure to react appropriately; access issues; and aggression.

4.6 What key factors prevent improvements to patient safety?


Could I suggest the organisation of work practices – I guess it relates to culture to some extent,
but just the way the processes of care are organised, the way that people are used to doing
it and sometimes they’re following a 100 year-plus method of apprenticeship, learning craft
delivery, and we’re in a completely different healthcare environment than we were 100 years
ago obviously, and yet the practices are essentially the same, instead of concentrating on the
organisation of workflow …. (Senior Health Executive Focus Group)

The factors identified by the 2004 focus groups as preventing improvements closely mirror the
participants’ previous concerns about the issue of patient safety. The focus groups identified a range
of issues at systems and organisational level (including finance, staffing, communication, workload,
co-ordination), and team (including communication, supervision) and individual levels.

Systems level issues included the need for patient safety strategies, guidelines and policies to be
introduced with greater attention to communication of their rationale and potential benefits (n = 2).
The need to consult people “at the coalface” in the development of new strategies was mentioned
by one group, while another identified the lack of assessment of the effectiveness of existing
strategies as something which prevented their full implementation. Finance and funding issues were
mentioned by several groups (n = 3).

If you went to the coalface and asked the people who are actually providing the care, they can
come up with some brilliant solutions, but they’re rarely asked, and if they don’t speak up and
suggest them then they’re never heard and it might take ten years to come out …. (Nursing
Focus Group)
31

Co-ordination between services was identified as a problem (n = 3), and both an acute and
community focus group (n = 2) identified the lack of 24 hour support for patients within their
homes as a significant concern. Difficulties in identifying, communicating with and handing
over to General Practitioners (GPs) was noted by the same groups as an issue in the longer
term safety of patients. In this last case, the impact of bulk-billing, the increase in large medical
centres rather than individual practices and the reticence of GPs to do home visits were issues
of note causing particular concern.

At an organisational level the matter of staffing once again ranked highly. Staff numbers were
identified by three groups as an issue, staff mix and level of experience by four groups, with an
additional two mentioning the increasing “casualisation rate” of staff. The implications of this
were seen as “… if we don’t grab hold of the challenges of training people in those situations
to be part of and recognised as part of the teams as they exist, then we’re gone ….” (Senior
Executive Manager). One group identified concerns about the Enrolled Nurse to Registered
Nurse levels, and expressed concern that this would be an increasing problem in the future.
Three groups mentioned their concern about the ability of staff to meet patients’ needs.

It is time consuming so it’s partly a time factor because you’re so busy trying to look after
your patient and then learning these new skills is taking extra time, to get everything
done on your shift. I stayed back until 11 o’clock the other night because I type with just
one finger and it was past 10 o’clock and I had to write my notes. I had to double check
everything. I had to deal with patients, equipment; there was an in-service on, etcetera….
(Senior Nursing Focus Group)

Resourcing for both staff and services was mentioned by five focus groups. Two groups
mentioned pressure from senior management about roles and workloads as potentially affecting
patient safety. Two groups mentioned the need to provide training with the introduction of new
technologies, and one group specifically mentioned the need for staff release to attend training,
and another supervision, in particular for junior staff (n = 2) as an additional concern. Workload
matters were raised by three groups, with one group mentioning in particular increases in
workload after the introduction of new safety systems.

… the junior medical staff … often have excessive expectations put upon them in terms of
their role and responsibilities by consultants … I think that always produced problems and
to change that really requires consultants to change their practices, how frequently they
come in, how frequently they review the patients, how much they let the registrars do on
their own and how much they actually supervise them. (Senior Nursing Focus Group)

Spanning organisational, team and individual levels were issues of communication and culture.
Discharge and care planning was identified at an organisational level (n = 2). Lack of effective
communication between staff was mentioned as a key factor preventing safety improvements
in five focus groups. One group also mentioned lack of communication during handovers and a
lack of other types of follow-up as a more generalised organisational-clinical problem.

Existing organisational and team cultural deficits were identified as a problem by five groups,
with one group also mentioning difficulty with resistance to change. An additional group
mentioned the need for “… better recognition of adverse events happening …” in other words an
increase in the acknowledgement of errors.
32 Giving a voice to patient safety in New South Wales

I think we need to change the culture of task orientation, to know that there’s more than just
the simple one, two, three things that you have to do for that patient – a more holistic point of
view, that there might be problems with a patient that are identified before something actually
happens. (Senior Executive Focus Group)

At an organisational and facility level, the workplace environment, including the layout of wards,
was also an issue (n = 2). Follow-up of recommendations of RCAs was identified by one group, with
another mentioning the need for greater creativity in seeking solutions to patient safety issues.

At an individual level, fear was identified as an obstacle to patient safety. Three groups mentioned
fear of litigation as affecting both clinician behaviour and patient safety. In one group a participant
offered the following observation “I still think there’s a big problem of litigation hanging over people’s
heads too. I think it has improved a bit in trying not to have the culture of blame so much ....” In two
cases, focus groups mentioned this fear manifested itself in hyper-vigilance:

So I can well understand where some of the junior doctors are coming from with regards to
over-ordering of tests, they are also aware that it’s becoming a more litigious environment and
they feel the more rudderless they are from up top and the less they feel they can ask, the
more they defend themselves with tests …. (Pathology Focus Group)

The 2007 focus groups identified a different range of issues, although within the same broad
categories of organisational, team and clinician concerns. In terms of organisational issues, it was
systems design, the impact of restructuring and amalgamation “the whole amalgamation of health
services on top of trying to drive the patient safety agenda, in a way that amalgamation dismantled
stuff that we already had in place, and we’ve had to go back and start again” (n = 3). The translation
of research into practice was equally seen as a major factor (n = 3) in preventing improvements.

We talk about evidence, and we spend so much money on research, but it never really gets
to practice – the service model, we still have the same old range of service models despite a
wealth of evidence that they need to change. (Management Focus Group).

Resource issues (n = 4), the volume of work (n = 2), and staff competency and skill mix (n = 2)
continue to be a concern, with the lack of administrative and middle management support receiving
special mention (n = 3). So were demands of increasing workloads on staff in general.

Attitudinal issues were also noted. The silo mentality was identified by one group as being a
problem, as were the attitudes of some staff to patient safety initiatives (n = 3) in general. Some
staff were seen as being affected by burn-out from “too many” different initiatives. The lack of
engagement of medical practitioners and senior clinicians in general (“it’s so hard to get medical
compliance on these sorts [TASC] of issues”) was identified by three groups. This was seen as
being the result of a lack of effective consultation with clinicians and indicated a need to develop
safety and quality improvement strategies specifically for this group.

I think that this [lack of clinician engagement] is because they see this as people running
around with clip-boards and the data they do see, they are not sure they can trust … what do
you do right at the very front about what you have to do about getting people to do it, why don’t
you talk to them? ... You need someone very senior and clinical to speak to someone very
senior and clinical to justify their practice. (Medical Focus Group)
33

4.7 If you could do one thing to improve patient safety, what would it be?
… the patient has got to be at the forefront of everybody’s mind really, that is not just from
the safety perspective, but you always think you have someone on the end of what you
are doing ... [and] something that goes hand in hand with that [is] working well above your
minimum professional standards, but also keeping the patient always in mind too …. (Allied
Health Focus Group)

The strategies identified by the 2004 focus groups as potentially improving patient safety closely
mirror the factors identified as preventing patient safety. Participants identified the following
categories of improvements: staffing; practice issues; culture; development; environment; and
systems and organisational issues.

Staffing was identified as a major factor in improvement, with ten groups identifying increased staffing
as their top priority, with two groups specifying increasing the numbers of Registered Nurses (RNs)
and one arguing for a general increase in experienced staff. Two groups asked for more planners,
one for discharge planners and the other for patient case managers. Two groups wanted more time
to spend with patients and another so that staff are “… not feeling so overwhelmed that they can
actually think about what they are doing and why they are doing it.” Workload was mentioned by two
groups, with one allied health participant making the following plea:

I would increase the number of medical staff in terms of junior doctors available because
the way they have been stretched creates some of the issues. They are not able to listen,
they are not able to attend the meeting and they are truly very stretched. I don’t know how
anyone can work under those conditions. (Allied Health Focus Group)

Practice issues can be essentially patient centred and staff centred. Patient centred issues
included a strong call for patient centred care (n = 8). Two groups suggested taking a holistic
approach to patient care, including pre-screening for issues such as nutritional levels, which
could translate into an increased risk of adverse events (such as pressure sores or infections)
later on.

In relation to staff, the creation of cohesive teams was identified by three groups as a key
issue, with one group mentioning in particular the need for teams with a mix of staff experience.
Improving communication between groups was mentioned by one group, with another identifying
the need for improved communication with patients. One group mentioned a need to increase
staff “heedfulness”, or keeping their focus on the job.

Cultural issues were raised by five groups. Two issues were identified. These were the need
for a culture shift (n = 3) in relation to patient safety, and the need for awareness, reflexivity and
responsibility in staff (n = 2).

… the thing I’ve seen most often is just inaccurate things on medical records, it just
happens because people rush, because they are not listening properly, because of poor
communication, all that sort of thing. They’re the sorts of mistakes I’ve seen, and I’ve seen
a lot of them, and all are completely understandable. I’ve seen very few things happen
because people are basically very poor at what they are doing. The things I’ve seen happen
have been due to stress or due to a particular system. But people are so defensive about
– rather than going ‘I was really tired’. So there’s defensiveness about not correcting things
so things get compounded. (Senior Nursing Focus Group).
34 Giving a voice to patient safety in New South Wales

Development was another strong category of suggestions for improvement. Peer review (n = 1),
education and training (n = 5), mentoring, involvement in RCA teams, compulsory peer reviews and
strategies for the reduction of isolation of staff (particularly, but not only locationally isolated staff)
were all identified.

Environment was seen as a factor for improvement for both patients and staff. For staff, one group
mentioned the need for a communal space, away from patients, within which staff could talk about
issues. For patients, the re-organisation of the ward environment for patients, and especially ageing
patients at risk of falls, was raised as a needed improvement. One group asked for increased
resources to improve the ward environment overall. A final group mentioned a successful strategy
that had already been implemented, as a model for the types of improvements they wanted to see:

I was working in rehab and their system had everyone in it. They have a tick list that asks
consultants ‘What are your goals? Have they been achieved? What is going on here?’ so they are
all demanding to get [the patient] out the door in a cohesive system, so that would be great, to do
that and have the consultants more involved on the ward level and for us, to be able to address our
issues as well. Then maybe, we can say to the patient ‘… these are your options. It is ultimately
your decision, and you can decide what happens’ …. (Allied Health Focus Group)

One of the largest groups of comments related to systems and organisational solutions. These
ranged from the very broad such as health care taking a proactive rather than a reactive approach
to patient safety and care (n = 2), including following patients through the system (n = 1), through
to the very specific, such as the re-institution of ward rounds led by NUMS, on a daily basis (n = 1).
A national mandatory reporting system was raised by two groups, as well as a patient identification
system (n = 2), dissemination of information and learning from safety initiatives (n = 1) and co-
operation between health care sectors (n = 1). Services in the community and improvements in
patient transport were each raised by one group. The standardisation of care at all levels (including
the institutionalisation of guidelines) was identified by three groups.

The suggested categories of improvements shifted slightly for the 2007 participants. Increased
staff and reduction in workloads continued to be a major issue (n = 5) for all discipline groups, but a
specific mention of middle management and administrative staff by two groups was new. Improved
communication at all levels of the system remained important (n = 3), with an emphasis on improved
consultation and communication at the “coal face” (n = 2). One group suggested that all services and
departments should “work collaboratively like aged care and rehab … with case conferences and family
conferences”. Improved staff competency (n = 2) was considered fundamental. Better use of information
technology was raised by two groups, particularly in relation to medical practitioners:

The IT strategy is nothing really clinical, its about patient administration, financial
administration, IIMS which is separate … there is a whole world of clinician decision support
that is just not there – it’s not even a branch of what they are doing … we all know it can be
done … some clinically linked thing that a specialist could say this is the pathway for this
condition and we could all be on the same page. (Medical Focus Group)

Improving the skills of clinicians as well as their procedures was identified as an issue by one group.
They saw the root cause not in individual error itself, but in the training and skills levels of some
clinicians:

If you do the wrong patient’s x-ray … as an example … that would be a SAC 1 – but what my
concern which is deeper is the number of unnecessary referrals in the first place, we are talking
about radiation, which are given in an emergency situation … lack of knowledge of junior
clinicians is much more important to look at. (Allied Health Focus Group)
35

4.8 Have you heard about the Institute for Clinical Excellence (ICE), now
the Clinical Excellence Commission (CEC)?
A final question related to participants’ views about the Commission. In 2004 there were high
levels of recognition of this organisation.

That’s the key of where the CEC needs to be. It needs to be the driver to facilitate change.
It has to be at that level or it’s never going to change…. (Senior Nursing Focus Group)

Of the 25 focus groups held in 2004, 24 (96%) of participants had heard either of the Institute
for Clinical Excellence (ICE) or the Clinical Excellence Commission (CEC). One group had not
heard of either of these organisations, and six groups had some members who had not heard
of them, but others had. In 2007 there was a similar level of awareness (96%). Participants
who were unaware of the CEC (n = 1) or unsure of what it did (n = 2) attributed their lack of
awareness to the fact that they had either been recently employed, recently arrived in the
country or because they were in rural services.

Focus groups were asked to make suggestions about the way in which the Clinical Excellence
could support and facilitate improvements to patient safety in NSW. In 2004 they made 53
contributions which we allocated to six categories: benchmarking, programs and activities,
culture change, approaches to patient safety, research and concerns. The responses are
presented in Table 8A.

Table 8A: Participants’ 2004 views on the way CEC could support and further
improvements to patient safety

Role and function of CEC (n = 53)

Benchmarking

Develop a standardised quality system (n = 1)

Establish clear quality goals and benchmarks (n = 4)

Review and standardise policies, guidelines and protocols (n = 4)

Accreditation for aged care sector (n = 1)

Identification of risk factors (n = 1)

Establish an integrative framework with professional and organisational bodies (n = 1)

Ensure auditing and evaluation of quality and safety programs (n = 1)

Identify resources, including technology, to improve safety (n = 1)

Review implication of staffing and workload levels for patient safety (n = 3)

Monitor appropriateness and use of IIMS and SAC criteria (n = 1)

Review organisations’ quality and safety infrastructure (staff, systems, guidelines) (n = 1)

Programs and activities

Long term programs to improve patient safety (n = 1)

Assist in the development of localised responses to patient safety (n = 1)

Support implementation of guidelines (n = 1)

Establish programs to reduce medication errors and falls (n = 1)

Improve quality of documentation in health services (n = 1)


36 Giving a voice to patient safety in New South Wales

Restructuring medical education (n = 1)

Support use of evidence based materials (including IIMS data) in educational and practice
programs (n = 2)

Advocate for finance (n = 1)

Review changes to health services for implications for patient safety (e.g. outsourcing of meals) (n = 1)

Sustaining existing safety and quality programs, like collaboratives (n = 1)

Education and training (n =2)

Culture change

Change clinician behaviour (n = 1)

Boost morale and pride in health service (n = 2)

Approach to patient safety

They need to be proactive about patient safety (n = 1)

Create user friendly approaches to change (n = 1)

Consult with and involve clinicians (n =2)

Acknowledge that quality and safety is an issue in community health (n = 1)

Maintain independence (n = 1)

Broad, strategic perspective on patient safety (n = 2)

Experience the system from the patients’ perspective (n = 1)

Review system down to individual clinician level (n = 1)

Research

Identify what is occurring in the clinical field (n = 1)

Identification of impact of communication issues on patient safety, including handovers (n = 1)

Concerns

Unless culture is addressed, nothing will change (n = 1)

Not sure a government agency can change clinical behaviour (n = 1)

Difficult to establish a new framework during restructuring (n = 1)

Preferred ICE (n = 1)

Tinkering around the edges (n = 1)

Concerned that they are just going to be a watchdog, and they should be much more than that (n = 1)
37

The 2007 participants made 34 suggestions. These are presented in Table 8B.

Table 8B: Participants’ 2007 views on the way CEC could support and further
improvements to patient safety

Role and function of CEC (n = 34)

Benchmarking

Develop a standardised quality system (n = 1)

Review and standardise policies, guidelines and protocols (n = 1)

Identification of risk factors (n = 1)

Ensure auditing and evaluation of quality and safety programs (n = 2)

Programs and activities

Models and advice on how to put safety and quality into practice (n = 1)

Programs to increase patient participation (n = 1)

Disseminate “frontline” examples of safety activities (n = 1)

Sustaining existing safety and quality programs, like collaboratives (n = 1)

Culture change

Engage senior clinicians (n = 2)

Approach to patient safety

Consult with and involve clinicians (n =2)

Maintain independence (n = 1)

Broad, strategic perspective on patient safety (n = 3)

Research

Provide a broader range of evidence (n = 1)

Identification of impact of communication issues on patient safety, including handovers (n = 1)

Concerns

CEC’s ability to reach down to clinician level (n = 3)

Confusion over the number of different Australian quality and safety bodies (n = 2)

Competing DOH and CEC priorities and reporting requirements (n = 4)

Lack of effective consultation before implementation of strategies (n = 3)

Lack of “visibility” including provision of updated information on activities and site visits (n = 3)

Participants were provided a handout asking about their knowledge of current ICE/CEC
activities, and their involvement in and evaluation of those activities (Appendix 5). The results of
the 2004 focus groups are presented in Table 9.
38 Giving a voice to patient safety in New South Wales

Table 9: Participants’ 2004 views on the patient safety strategies of CEC

Patient Safety Strategies

I have heard of I have participated I believe this strategy is


Strategy
this strategy in this strategy effective

Yes No Yes No Yes No N/A

Blood Transfusion
54 69 10 82 27 3 65
Improvement
(43.9%) (56.1%) (10.9%) (89.1%) (28.4%) (3.2%) (68.4%)
Collaborative (BTIC)

Clinical Governance
74 51 11 80 36 4 6
Development Program
(59.2%) (40.8%) (12.1%) (87.9%) (78.3%) (8.7%) (13.0%)
(CGDP)

Patient Flow and Safety 72 51 24 74 40 8 56


Collaborative (PFSC) (58.5%) (41.5%) (24.5%) (75.5%) (38.5%) (7.7%) (53.8%)

Clinical Risk 12
30 90 3 85 3 8
Management for Rural (52.2%)
(25.0%) (75.0%) (3.4%) (96.6%) (13.0%) (34.8%)
GPs (CRMRGP)

Safety Improvement 78 44 32 64 42 3 53
Program (SIP) (63.9%) (36.1%) (33.3%) (66.7%) (42.9%) (3.1%) (54.0%)

Towards a Safety 46 76 16 77 26 2 67
Culture (TASC) Project (37.7%) (62.3%) (17.2%) (82.8%) (27.4%) (2.1%) (70.5%)

Research Program
4 81 10 81 19 1 77
into Safety and Quality
(4.7%) (95.3%) (11.0%) (89.0%) (19.6%) (1.0%) (79.4%)
(RPSQ)

Root Cause Analysis 88 34 37 66 57 7 40


Training (RCAT) (72.1%) (27.9%) (35.9%) (64.1%) (54.8%) (6.7%) (38.5%)

446 496 143 609 259 31 372


Total
(47.3%) (52.7%) (19.0%) (81.0%) (39.1%) (4.7%) (56.2%)

In 2007 there was increased awareness of all of the CEC’s programs. Of the participants who
responded to each question: 63.6% had heard of BTIC; 61.5% of CGDP; 81.1% of PFSC; 36.4% of
CRMRGP; 75% of SIP; 58.3% of TASC; 54.5% of RPSQ; and 100% had heard of RCA training.

Participation in these strategies had also increased in all cases except the CRMRGP (no participants
from the 2007 focus groups had been involved in this strategy) and TASC, which had fallen to 12.5%.
A total of 66.7% of all participants in 2007 who responded had been involved in BTIC; 40.0% in CGDP;
37.5% in the PFSC; 62.5% in SIP; 42.9% in RPSQ; and 60.0% in RCA training.

Belief in the effectiveness of training had also increased or stayed virtually the same across
the board. Of the participants who responded to each question the following thought that these
strategies were effective: 60.0% - BTIC; 87.5% - CGDP; 80.0% - PFSC; 40.0% - CRMRGP; 100%
- SIP; 71.4% - TASC; 66.7% - RPSQ; and 100% - RCAT.

4.9 Additional comments


Time allowing, participants were given the opportunity to add any comments or reflections at the
end of each focus group. In 2004 ten focus groups provided 29 additional issues they wished to see
raised. These are presented in Table 10, grouped into four categories: systems, organisations, team,
professional and individual issues. In 2007, the majority of respondents felt that they had addressed
issues in the previous questions.
39

Table 10: Additional comments in 2004

Additional comments (n = 29)

Systems issues

Increased resources in the community (n = 2)

Patient safety collaboratives in smaller hospitals (n = 1)

Patient safety collaboratives outside of acute care (n = 1)

Re-coupling of quality and safety (n = 2)

Increased resources (n = 1)

Co-ordination of national and state-wide approaches to safety (n = 1)

Use of legislation and benchmarking to encourage compliance (n = 1)

Increase number of nurses (n = 1)

Capturing more information (n = 1)

Organisational issues

Increased education and training for staff (n = 1)

Staff to assist in transition from hospital to community (n = 1)

Improved feedback on patient outcomes (n = 1)

Positive cultural change and systemic approaches linked with accountability and involvement of
medical staff (n = 2)

Improvement rather than punitive approaches (n = 1)

Use of information technology, including bar-coding and electronic records (n = 1)

Checking and review processes in pathology (n = 1)

Encouragement of safety champions (n = 1)

Team/professional issues

Multidisciplinary teams that include biostatisticians and epidemiologists (n = 1)

Increase accountability (n = 1)

Recognition of managers’ stress (n = 1)

Assumed knowledge by health professionals about other disciplines, especially nutrition (n = 1)

Improvements to infection control (n = 1)

Individual issues

Fear of lack of support for staff post Camden and Campbelltown (n = 2)

Acceptance of responsibility for errors, including from senior medical staff (n = 1)

Fear of media hindering genuine safety improvements (n = 1)

In the 2007 focus groups, participants were asked about the impact of the CEC over the previous
three years. The CEC was seen has having contributed to the improvements in patient safety
particularly through the TASC Project, the BTIC and a range of other strategies and initiatives
including IIMS. A number of groups commented on the difficulty of the CEC’s role and position,
especially in its task of leading system wide change.
40 Giving a voice to patient safety in New South Wales

Three issues were seen as currently limiting the CEC’s significant potential impact on health
service delivery. The first was the visibility of the CEC as an entity independent of the DOH, and
distinguished from other quality and safety bodies. The second was the perceived lack of effective
consultation to AHSs and then to the “grass roots” levels of health services (i.e., to clinicians) and
the CEC’s ability to respond to the needs of people at those levels. Third was the need to improve
co-ordination between CEC and DOH requirements and strategies in order to reduce frustration
amongst managers and clinicians about which activities to prioritise. One focus group pointed out
that some of the issues which were perceived as limiting the CEC’s effectiveness were currently
being addressed by the CEC and that significant improvements had been made in co-ordination and
communication with AHS over the last couple of months. This positive change was attributed to new
staff at the CEC.

Participants in 2007 also provided some additional suggestions about the future activities of the
CEC. These were very similar to those identified in 2004. They included: the careful selection by
CEC of key issues or themes for co-ordinated safety improvement efforts (suggestions included
risk analysis, handover, deteriorating patients, clinical report writing); increased public and clinician
profile, including improvements to feedback and communication to all levels of health services;
return to site visits; provision of best practice models and examples of frontline interventions;
provision, co-ordination and direction of safety and quality educational activities; and specific
strategies to engage senior and other clinical staff.

5 Discussion

These results show that the issue of patient safety in NSW has been identified as a challenge requiring
cohesive and coordinated solutions. The dimensions of the problem have been defined by staff drawn from
various levels and disciplines. Central to the responses was the issue of communication: difficulties and
breakdowns in communication, in its various forms, more than any other factor, was seen as contributing to
past and present adverse events.

While central to the problem and its solutions, communication was not the only factor. Broad systems issues,
especially the question of workforce shortages, training and skills levels were common concerns, particularly
from managers. Groups from all disciplines raised questions of adequate workloads, and the issue of time:
time for training, time for reflection, and time to care adequately for, as well as treat, patients. Restructuring
was also seen as a barrier to continuous improvements. Changes in patient profiles, in particular increasing
numbers of seriously ill patients, patients with mental illness, and patients with cognitive and communication
problems were seen as contributing to the need for highly skilled and focused health practitioners.

Progress has been made in addressing patient safety. Developments in incident reporting and error analysis
provides an indication of recent and significant changes. Many staff think the NSW health system is on the right
track toward improvement, notwithstanding the challenges that lie ahead. The health system and individuals
are responding to patient safety concerns. The willingness of many participants to report errors, discuss their
concerns with management and colleagues, and participate in rapid reviews and responses can be seen as
suggesting that changes are occurring in the safety culture. So too can the fact that the majority of changes
in recent years were seen as positive; the increased focus on governance and safety, was seen as a step
forward, for example. Several groups argued for further increases in levels of accountability and responsibility
of staff. There was support for the shift away from the old “blame and shame” culture.
41

Commitment to the current direction in addressing medical errors and adverse events, as well as a
belief that there is more work to be done, can be seen in the perspectives adduced in this study. We
can be cautiously optimistic, particularly as the results from the latest focus groups showed a sustained
commitment to safety improvement and a maturation of concerns, including the need to sustain and embed
systems and practice improvements.

However, in a number of responses, some participants raised concerns about the level of support they
do and would receive in the event of a major adverse event. Obstacles or factors which were seen as
inhibiting improvements to patient safety, aside from staffing levels, centre on communication and teams:
communication between the health care system and management and staff; teamwork between staff, in
particular across disciplines; interaction between teams and services, especially with GPs; and integration
of effort between professionals, patients and their carers and families. In recent years the impact of
restructuring and amalgamations, limited resources and the workforce skill mix were seen as slowing if not
impeding safety improvements.

Participants’ experiences with adverse events and errors, while distressing, are increasingly common.
The concern of participants was less about blame than in the past. Accountability remains a significant
issue, and the need to take a proactive, rather than reactive approach. All groups were able to provide
examples of both minor and major adverse events. They were also able to provide examples of advances
and improvements either currently underway, or which they are hoping to see in the near future. It is in this
context that the role and value of the CEC to the practising health professional becomes apparent.

Participants provided a wide range of suggestions as to the potential role and contribution of the CEC to
their work lives. Four major categories were identified including establishing benchmarks, conducting new
programs and activities, facilitating culture change, and undertaking research. In addition, participants had
some definite suggestions about the approach the CEC should take: it should be proactive, strategic and
consultative, and inclusive of stakeholders, especially of professionals and patients. CEC, for its part, is
starting to do this, as its Directions Strategy, Annual Reports and other documentation make clear. [www.
cec.health.nsw.gov.au/]

6 Conclusion

The information presented in this report shows that patient safety is more than a set of technical problems;
rather, it is an organisational issue. The health professionals who gave their time and expertise to speak
in the focus groups made one point very clearly: the issue of patient safety had affected them all. Their
candour in speaking about the issues of medical errors and adverse events, the way in which they were
willing to discuss events that had happened to them or those close to them, and the depth at which
they were all, new graduates and senior executives alike, able to speak about the causes and possible
solutions, was testimony to the professionalism with which they engage with this issue.

None of that is, perhaps, surprising. The people we spoke to are health professionals who are dedicated
to preserving and improving people’s lives, and who, by nature of the research sampling process, are also
people who were willing to come forward and speak openly in a group setting about this issue. What was
telling, however, was the depth of their concern, the passion and commitment to tackling patient safety, and
what this passion and commitment meant to them. The message was loud and lucid: the advancement of
patient safety is as important for the majority as the advancement of health. The challenge is not merely
about the need to improve patient safety, but rather, finding ways in complex, changing, increasingly
42 Giving a voice to patient safety in New South Wales

scrutinised workplaces so that safety is improved to the benefit and satisfaction of both patients and health
professionals. There was a firm belief that patient safety problems occurred not so much as a result of
individual error, but rather as a result of a combination of poor communication, ineffective teamwork, cultural
barriers or inadequate or inappropriate resource management. This is not to say that everyone in every group
agreed: in some isolated cases, individuals felt that the concerns about patient safety had been conflated
somewhat, particularly by a sensationalist media.

An unanticipated finding of the research was the strength with which staff essentially held that they, as well
as patients, were vulnerable within the health system. Participants’ major concerns about patient safety
reflected this dual apprehension. The most common concern was lack of trained, reliable staff, in virtually all
disciplines, and poor coordination of care. Closely tied to this were the issues of resources and the distribution
of resources across the health system. These require concerted improvement over time.

Staff spoke about the way in which changes to the health system had affected them, and their patients, in
recent years. On a negative note were high levels of uncertainty, staff shortages and for some a sense of
exhaustion in trying to keep up with the pace of change in almost all aspects of service delivery – from policy
development through to practice. On a positive note, the increased concern with patient safety as a whole was
seen as highly valuable, and it was encouraging for our participants to see programs, and to observe multiple
initiatives, which they thought were beginning to pay dividends.

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8 Appendices

8.1 Appendix 1: Summary of focus group questions


Table 11 summarises the key questions asked of the participants in the focus groups. Questions
were slightly modified according to the location of the group, so for example state-wide groups were
asked to consider the issue from that perspective, rather than from an individual facility perspective.
Supplementary and probing questions were also used to expand the discussions where appropriate.

Table 11: Summary of Focus Group Questions

Key focus group questions

1) In terms of patient safety, what keeps you awake at night?


2) Have your concerns about patient safety changed in recent years? Why?
3) Do you think there are people or groups who are at higher risk in the health system?
4) Can you tell me about the last incident that you observed/heard about that caused harm to a patient
or prolonged their care?
a) Could you please look at Handout 1, and give us an estimate of the numbers of adverse events you
have observed?
5) What are we doing well in relation to patient safety?
a) Could you please look at Handout 2, and tell us about responses to adverse events
6) What key factors prevent improvements to patient safety?
7) If you could do one thing to improve patient safety, what would it be?
8) Have you heard about the Institute for Clinical Excellence now the Clinical Excellence Commission
(CEC)? What impact has it had? What do you think it should focus on?
a) Handout 3 has a list of CEC patient safety strategies. Could you please take a moment to answer
the questions on that sheet
9) Is there anything else I should have asked, or you would like to add?
47

8.2 Appendix 2: Demographic questionnaire


The Centre for Clinical Governance Research, University of NSW has been asked by the NSW
Department of Health and the Clinical Excellence Commission to undertake research into the impact of the
Commission’s programs to improve the safety and quality of healthcare. The following data are collected
to provide a basis for comparison for responses between focus groups.

Completion of this form is entirely voluntary.


If you choose to complete this form, the information will be completely confidential.

1. Are you (please tick): q Male q Female

2. What is your age: ________years

3. In which country were you born?

4. If you were born overseas, please indicate the year you arrived in Australia:

1. Are you of Aboriginal or Torres Strait Islander background? q Yes q No

2. What is your profession or occupation?

3. How many years’ experience do you have in this profession/occupation?________ years

4. What is your job title?

5. What is your current role(s) at work?

6. How long have you been in this role?_________years _ ________ months

7. What is your highest qualification?

8. In which year did you complete that qualification?_ _________ year

9. Are you a manager? q Yes q No

10. If you work for an Area Health Service, please indicate which one:

11. In what type of facility or organisation (e.g. hospital, CHC, Department of Health/Branch etc) do you work?

12. How long have you worked for your current facility/organisation?_________ years ________ months

13. Have you completed NSW Health’s Root Cause Analysis (RCA) Training? q Yes q No

14. Have you been on any RCA teams in your facility? q Yes q No If yes, how many?
48 Giving a voice to patient safety in New South Wales

8.3 Appendix 3: Handout 1 - rates of adverse events

Part A: Rates of adverse events


For the purposes of these questions, an ‘adverse event’ is an unplanned, undesirable event that has a
negative consequence.

1. Thinking of patients in your facility over the last year, how many have suffered an adverse event?

2. How many have had Root Cause Analyses conducted on them?

3. Please provide an example of a minor adverse event:

3 a) What percentage of all adverse events that you know about, do you think are minor?

4 Please provide an example of a major adverse event:

4 a) What percentage of all adverse events that you know about do you think are major?
49

Please place only one tick on each line.

5. How often do you think the following medical errors occurs within your AHS:
Every A couple Once a
Daily Weekly Monthly couple of of times a year or Never
Months year less

Errors or delays in diagnosis

Failure to employ indicated tests

Use of outmoded tests or


therapies

Failure to act on results of


monitoring or testing

Failure to provide prophylactic


treatment

Inadequate monitoring or follow-


up of treatment

Errors in the performance of


operations

Errors in the administering of


treatments

Errors in the dose or methods of


using a drug

Avoidable delays in treatments


or responding to abnormal tests

Errors in the performance of


procedures

Inappropriate (not indicated) care

Errors in the performance of tests

Failure of communication

Equipment failures

Other systems failures


50 Giving a voice to patient safety in New South Wales

8.4 Appendix 4: Handout 2 - responses to patient safety

Part B: responses to patient safety

6. Could you briefly tell us your facility/service’s response to the last adverse event you observed?

7. Do you think this response was (please tick):

Effective q Yes q No

Efficient q Yes q No

Ethical q Yes q No

8. Who do/would you go to when an adverse event happens (within your facility/service)?

9. Do you feel you have the authority to need to get action about your concerns? q Yes q No

10. What do you think is most likely to cause the next adverse event in your facility/service?
51

8.5 Appendix 5: Handout 3 - patient safety strategies

Please Answer Every Question

I have I believe this


I have heard of
Safety Strategy participated in strategy is
this strategy
this strategy effective

Blood Transfusion Improvement


q Yes q No q Yes q No q Yes q No
Collaborative (BTIC)
Clinical Governance Development
q Yes q No q Yes q No q Yes q No
Program (CGDP)
Patient Flow and Safety Collaborative
q Yes q No q Yes q No q Yes q No
(PFSP)
Clinical Risk Management for Rural
q Yes q No q Yes q No q Yes q No
GPs (CRMRGP)

Safety Improvement Program (SIP) q Yes q No q Yes q No q Yes q No

Towards a Safer Culture (TASC) q Yes q No q Yes q No q Yes q No

Research Program Into Safety And


q Yes q No q Yes q No q Yes q No
Quality (RPSQ)

Root Cause Analysis Training (RCAT) q Yes q No q Yes q No q Yes q No

Other (specify): q Yes q No q Yes q No q Yes q No

Other (specify): q Yes q No q Yes q No q Yes q No