The delivery of health care is associated with a high error rate compared with other complex industries. Traditional medical quality assurance has resulted in much activity often lacking integration and resulting in disappointingly small and inconsistent improvements in the quality of patient care (with a few exceptions in specific areas). This summary describes a comprehensive clinical risk management program designed to integrate the detection and reduction of adverse patient events as part of the everyday activity of an acute general hospital.

Clinical risk management is about reducing the probability of negative patient events. This involves firstly detecting adverse events then analysing their risk severity and taking appropriate action to prevent their recurrence. The Wimmera Clinical Risk Management Project began this process by developing several methods for detecting adverse events. The initial detection method was medical record review using a two step process of screening all inpatient medical records using general medical outcome criteria (e.g. return to the operating theatre, readmission within 21 days of discharge) and then medically reviewing those records that screened positive. This method detects many adverse events in an effective and efficient manner. Analysis of these adverse events and the taking of appropriate action has resulted in a significant reduction in the rate of inpatient adverse events that has been sustained over ten years.

The two step process has been modified for use in reviewing emergency department medical records. These modified screening criteria have been in use for over 11 years and have allowed efficient detection of adverrse events in the emergency department. Appropriate action has then been taken whcih has reduced the  rate of adverse events. .

 To improve the detection of adverse events a coordinated method of clinical incidents being reported by staff members was introduced. Clinical incidents and near misses are reported by staff both to the hospitals involved in this program and to a national database of the Australian Patient Safety Foundation. The most common incident reported has been patient falls (47.7% of all incidents reported). Using a patient falls risk assessment tool and appropriate action to prevent falls a significant reduction in the number of falls resulting in fractures has been achieved over three years. A significant finding was the low overlap of adverse events detected by both the medical record review process and clinical incident reporting. Each detection method appears to find adverse events from a different pool.

Despite using these comprehensive methods to detect adverse events, some events are still not found.  An adverse event may occur after a patient is discharged from hospital but the event may be due to their treatment while they were in hospital. For example, a wound infection after surgery may develop several days after discharge.  To capture this important information, each hospital inpatient discharge summary that is sent to the patient’s general practitioner also contains an adverse patient event reporting form. If the patient’s general practitioner detects an adverse event after discharge it can easily be reported to the clinical risk management program. This process detects adverse events that are often not recorded in the hospital medical records and have not been reported by hospital staff.

Some adverse events occur infrequently and may only be detected once every few years in individual hospital clinical risk management programs. To maximise the benefit of this pool of valuable information about serious but infrequent events, information has been used about adverse events that have occurred at other hospitals as if the event has actually occurred at Wimmera Health Care Group. Information about such adverse events is available from coronial reports, consultative committee annual reports (e.g. The Consultative Council on Obstetric and Paediatric Mortality and Morbidity, The Victorian Consultative Council on Anaesthetic Mortality and Morbidity and the Victorian Surgical Consultative Council), hospital insurers, medical indemnity organisations and clinical journals.  After an adverse event is reported by one of these sources, the question is asked could this adverse event occur here? If the answer is yes, analysis and action are taken to reduce the probability of such an event occurring.  It is not necessary for a hospital to wait to actually experience a particular low frequency adverse event to benefit from it having occurred elsewhere.

In a similar preventative vein, undertaking a risk assessment on each patient admitted to the hospital can prevent common adverse events. For example each patient over 65 years of age who is admitted to the hospital undergoes a falls risk assessment. Those patients assessed as high risk for having a fall while in hospital are managed on adjustable height beds and in rooms close to the nurses’ stations so that assistance is close at hand if required. 

There is sometimes a delay in adverse events being detected by reviewing medical records or by staff members reporting clinical incidents. To capture the details of more adverse events shortly after they occur, the use of evidence-based clinical pathways for particular clinical situations will be expanded for both inpatients and emergency department patients. Variances from pathways can be reported at the time they are recorded in the medical record and analysis of the variance will be undertaken promptly.

Although research has shown patients to be poor judges of the quality of the clinical care they receive, they are able to accurately assess the quality of non-clinical care which is a significant component of the quality of care and service provided by hospitals. Information from patients provides valuable data for improvement of systems in hospitals. Adverse events that have occurred from the patient’s perspective are also detected. This is achieved using information from patient satisfaction surveys, focus groups and patient complaints.

In this clinical risk management program it has become apparent that it is not possible to manage the risk associated with all the adverse events detected. Therefore as each adverse event is detected the risk associated with the event is determined. The probability and consequences of the risk are assessed and a risk severity rating is given to the adverse event in accordance with the Standards Australia Risk Management Standard. The adverse events are then ranked according to their risk severity rating. Those with the most severe rating are given priority for analysis and action aimed at eliminating or reducing their risk. In the case of adverse events with low risk severity, a decision is made as to whether to take action or to accept the risk and continue monitoring the particular adverse event.

The actions taken to manage clinical risk have been a large component of this program to date. After an adverse event has been detected, the risk is analysed and if the risk severity is high a multidisciplinary team is assembled. An aim for quality improvement is established by the team together with a balanced set of  process and outcome measures. Options to improve systems involved in the adverse event are derived empirically or from research (where possible evidence-based) or observation and are examined in detail. Small-scale tests are undertaken to implement chosen improvement strategies after baseline measurements are taken. Measured results of the tests are analysed and improvement strategies are adopted, modified or abandoned. Further small tests are then undertaken if required, following the same sequence. This strategy has underpinned the significant improvements that have been achieved in the adverse event rates in this clinical risk management program.

A major component of the system improvements program has been the implementation of the results of research into error prevention. Adverse events are analysed to identify latent factors (e.g. workload, level of supervision, communication and equipment) and active factors (e.g. memory lapses and slips) that contributed to the error occurring. Actions taken have concentrated on improving the work environment and removing total reliance on the weakest components of human cognitive function especially short-term memory and the ability to be distracted from the task at hand. Strategies utilised to address these issues include simplification of systems, standardisation of procedures, use of reminders and checklists, and the timely delivery of information. 

Information from the program is regularly reported to participating doctors, clinical staff and hospital quality assurance committees and boards of management.

Reducing the probability of adverse events occurring in hospitals requires a comprehensive and integrated approach to detecting adverse events, analysing the events and taking appropriate action to successfully reduce the chances of the events recurring. The process requires support from senior clinicians and executive staff, board of management members and all health care professionals working at a hospital.  The work is labour intensive and requires additional resources. However the rewards of improving the level of patient safety are attainable and significant. The establishment and maintenance of an effective clinical risk management program is a worthy objective for all hospitals.

Example clinical pathways:

Stroke clinical pathway
STEMI clinical pathway

• Wolff AM, Limited adverse occurrence screening: using medical record review to reduce hospital adverse patient events. MJA 1996; 164:458-461.
  http://www.mja.com.au/public/issues/apr15/wolff/wolff.html
  
• Wolff AM, Bourke J. Detecting and reducing adverse events in an Australian rural base hospital emergency department using medical record screening and review. Emerg Med J 2002; 19:35-40.
  http://emj.bmj.com/cgi/reprint/19/1/35
  
• Wolff AM, Bourke J. Reducing medical errors: a practical guide. MJA 2000; 173: 247-251.
  
• Wolff AM, Bourke J, Campbell IA, Leembruggen DW. Detecting and reducing adverse events: outcomes of the Wimmera clinical risk management program. MJA 2001; 174: 621-625.
  http://www.mja.com.au/public/issues/174_12_180601/wolff/wolff.html
  
• Wolff AM, Taylor SA, McCabe JF. Using checklists and reminders in clinical pathways to improve hospital inpatient care. MJA 2004; 181:428-431. http://www.mja.com.au/public/issues/181_08_181004/wol10318_fm.html

Quality of Care Report - 2007/08

Quality of Care Report - 2006/07

Wimmera Health Care Group Credentialing Document

The Department of health requires that this document be completed for all medical appointments at Wimmera Health Care Group (new and recurring).  Please download the form on the link below, complete and return to Medical Administration, Wimmera Health Care Group, Baillie Street, Horsham Vic 3400.

WHCG Credentialing Document