News
APSF Annual Report 2008-09
11/01/2010
The Annual Report outlines the activities and achievements of the Australian Patient Safety Foundation for financial year 2008-2009.Office move
19/11/2009
The APSF has recently moved offices and is now based in the Playford Building at University of South Australia, City East Campus.
The move will allow closer ties with the Human Factors and Safety Management Systems group in the Centre for Sleep Research, and other research groups based in the University.
The APSF contact and postal details will remain unchanged, but our physical address is now:
c/o School of Psychology
Level 1 Playford Building
UniSA City East Campus
Radiology Incident Reporting in New Zealand
16/10/2009
The Radiology Events Register (RaER) has recently been declared a protected Quality Assurance Activity in New Zealand. This means that diagnostic and interventional radiologists practicing in New Zealand can report an incident into the RaER database and that:
- any information that becomes known solely as a result of the activity is confidential;
- any documents brought into existence solely for the purposes of the activity are confidential; and
- the persons who engage in the activity in good faith are immune from civil liability.
For more information about the Radiology Events Register or to report an incident, please visit http://www.raer.org/
For more information about Quality Assurance Activities in New Zealand, please refer to section 54 of the Health Practitioners Competence Assurance Act 2003, accessible from http://www.legislation.govt.nz/default.aspx
PhD Scholarships in Patient Safety
24/09/2009
The NH&MRC Patient Safety Program is offering up to ten PhD scholarships
- Career defining roles in the field of patient safety;
- University of NSW, University of Sydney and the University of South Australia
Candidates are invited from a variety of academic backgrounds such as but not limited to: sociology, psychology, medicine, informatics, science, public health, computing or pharmacy.
The scholarship provides an annual tax-exempt stipend of $26,669 for three years full time with the possibility of a six month extension and will be awarded on a competitive basis. The scholarships will commence in 2010 or 2011.
Applications must include the following:
· curriculum vitae
· a certified copy of academic transcripts
· proof of citizenship or permanent residency
· the names and contact details of at least two referees
· the names of preferred PhD supervisor and co-supervisor.
More information is available from the Patient Safety Program website: (http://www.med.unsw.edu.au/medweb.nsf/page/PSP)
Please contact Professor Jeffrey Braithwaite j.braithwaite@unsw.edu.au in the first instance for further information.
After discussion, preferred applicants will submit an application for admission to a higher degree research program.
http://www.grs.unsw.edu.au/futurestudents/apply.html
http://www.usyd.edu.au/ro/training/postgraduate_awards.shtml
Content development and review for International Classification for Patient Safety
18/08/2009
The Australian Patient Safety Foundation (APSF), led by APSF President Professor Bill Runciman, has been engaged by World Health Organisation Patient Safety to develop content for the International Classification for Patient Safety (ICPS).
The project involves populating version 1.1 of the ICPS Conceptual Framework with patient safety classifications and ontological relationships from a diverse group of international sources, including the Advanced Incident Management System. The APSF team will then coordinate the review of this material by international experts.
In the first instance, two types of patient safety healthcare incident types – falls and pressure ulcers – will be included. Subsequent work will examine all incident types included in the ICPS.
More information on the project, including the version 1.1 of the ICPS Conceptual Framework, is available from:
http://www.who.int/patientsafety/implementation/taxonomy/en/index.html
Patient Safety Think Tank
03/03/2009
The Australian Patient Safety Foundation and Human Factors and Safety Management System at the University of South Australia are hosting a patient safety Think Tank in Adelaide on March 5-6.
The Think Tank "Humans and Complex Systems: The good, the bad and the ugly" will feature internationally renowned speakers in Patient Safety, Human Factors, Error and Health Informatics.
The program has been designed to provide a catalyst for innovation in the design of error tolerant and resilient systems. The Think Tank will be of interest to researchers, safety and quality personnel, policy makers and clinicians.
Registration forms are available here, and the Think Tank program can be downloaded here. For more information, contact Fiona Dennis (fiona.dennis@unisa.edu.au), or visit the Think Tank web page at http://www.unisa.edu.au/safety/
Two APSF Council Members Awarded $8.4 Million NHMRC Grant
14/11/2008
A major program of research to reduce the number of patients harmed in Australia's hospitals has been awarded $8.4 million in the latest round of National Health and Medical Research Council (NHMRC) grants.
'A million adverse events occur in general practice each year in Australia,' said Professor Jeffrey Braithwaite, one of the project's Chief Investigators and Chairman of the APSF. The team is looking at underlying problems in Australia's health system that harm one in ten hospital patients each year.
The team leaders are internationally recognised for their exceptional leadership in the field of patient safety. They bring together clinical expertise and research and evaluation skills to solve very challenging problems. The team comprises five researchers: Professors Jeffrey Braithwaite, Enrico Coiera, Ric Day (University of New South Wales), Johanna Westbrook (University of Sydney) and Professor Bill Runciman (University of South Australia/ Joanna Briggs Institute and President of the Australian Patient Safety Foundation).
'Overseas data shows that patients receive recommended care only half of the time,' said Professor Braithwaite. 'We will significantly advance this work by investigating how and why this occurs, with a focus on the roles of teamwork, safe medication use and the application of information technology to support improved decision-making.'
Professor Braithwaite, who is Director of the Institute for Health Innovation at UNSW, says there is a lack of evidence about what works in improving patient safety.
'Quality and safety of care are now at the very top of our national health agenda, but everyone is struggling to solve this complex systems problem. We simply cannot afford to keep doing more of the same.'
Source: University of New South Wales press release: http://www.unsw.edu.au/news/pad/articles/2008/nov/NHMRC.html
Sidney Sax winner 2008 Professor Bill Runciman
03/10/2008
The Australian Healthcare and Hospitals Association (AHHA) is delighted to announce that the winner of the Sidney Sax medal for 2008 is Professor William (Bill) Runciman.
The AHHA awards the annual Sidney Sax Medal to an individual, active in the health services field, who has made an outstanding contribution in the field of health services policy, organisation, delivery and research.
The AHHA is the peak national body representing public hospitals, area health services, community health centres and public aged care providers.
"Professor Runciman has provided outstanding leadership and made fundamental contributions to patient safety and quality research both in
"Bill was educated in
"In 1988, Bill founded the Australian Patient Safety Foundation (APSF) and is still the organisation's President. In 1988, together with APSF colleagues, he conceptualised and implemented the AIMS Incident and Risk Management Program - in the form of a nation-wide paper-based anaesthesia incident monitoring project. Today, the AIMS incident management software is in use at more than 1000 facilities in
"Bill has furthered national and international work on patient safety by contributing his expertise on many organisations and committees and has received numerous professional awards. He has an impressive record of research focused on risk management, patient safety, quality assurance, cost-benefit analysis and resource allocation. He has been involved in the publication of about 200 scientific papers and chapters, has co-authored a textbook and has given 500 lectures by invitation.
"AHHA congratulates Professor Runciman on this award and his lifetime contribution to improving the safety and quality of health care," Ms Power said.
Professor Runciman of the APSF Appointed to U.S. National Quality Forum Common Formats Experts Panel
12/09/2008
The Common Formats Expert Panel is part of a federal
Professor Runciman is a world renowned patient safety pioneer and a highly respected intensive care specialist. He has spent much of the last 25 years researching patient safety problems and developing new approaches and tools to reduce harm in the delivery of care. In addition to being the founding president of the Australian Patient Safety Foundation, Bill is Professor of Patient Safety and Human Factors in Healthcare, at the
About the Australian Patient Safety Foundation:
The Australian Patient Safety Foundation Inc. (APSF) is a non-profit independent organization dedicated to the advancement of patient safety. The APSF provides leadership in the reduction of harm to patients in all health care environments.
www.apsf.net.au
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Contacts
Australian Patient Safety Foundation
Delia Dent +61 (0)410 575 123
delia.dent@apsf.net.au
A new addition to APSF staff
05/08/2008
APSF welcomes back Natalie Hannaford, from her secondment at the South Australian Department of Health. Natalie works part time at APSF as a Senior Analyst and will be working on a range of AIMS related projects in the coming months.New staff at the APSF
28/05/2008
The APSF recently farewelled Technical Director Peter Hibbert who has moved to the UK to work for the NHS as Associate Director, Clinical Teams, Patient Safety Division, National Patient Safety Agency. Peter's role is to manage clinical teams in the areas of primary care, anaesthesia and surgery, maternity and child health, and mental health with the aim of producing clinically foucssed patient safety advice, reports and guidelines. After four and a half productive years at the APSF, we wish him all the best in this challenging new role.
Peter's position has been taken by Dr Tim Schultz, who will continue to work for the Joanna Briggs Institute on a part-time basis.
APSF Annual Report 2006-2007
20/12/2007
The Australian Patient Safety Foundation's Annual Report outlines the resources produced, presentations and papers given and projects undertaken for the financial year 2006-2007.The Collaborations for Translating Evidence into Practice (CTEP) Program
28/06/2007
The inaugural meeting of the “Collaborations for Translating Evidence into Practice” (CTEP) was held at Coogee on June 21-22, 2007. The meeting was attended by 30 influential leaders in health care to discuss proposals to establish clinician led reform of the health system.
The presenters were:
Professor Bill Runciman: An Overview of the problem - an international perspective and Setting priorities: evidence from the USA, UK and Australia
Ian Scott: An Australian perspective
Jeffrey Braithwaite: Evidence for translating evidence into practice
Dr Mike Stein: The Map of Medicine
Professor Alan Pearson: Nursing and aged care guidelines
Dr Annette Pantle: An Australian story
Professor Bruce Barraclough: Issues with surgery
Professor Alan Wolff: Issues with general practice
Professor Cliff Hughes: Issues with medication management
Professor Heather Gibb: Issues with nursing and aged care
A Coogee Charter was agreed by the meeting delegates:
“The aim is to improve safety and quality of healthcare through clinician-led collaborations by setting and implementing national clinical standards to translate evidence into clinical practice and show measurable improvement by 2010.”
This will be done by setting up a series of Collaboratives that are based on specific problems. An open invitation to participate be issued to all with an interest in that area.
The meeting was organised by the Joanna Briggs Institute, the Australian Patient Safety Foundation, the Centre for Clinical Governance Research in Health and kindly hosted by the Centre for Health Informatics at the University of New South Wales. The organisers would like to thank the Western Australian Department of Health, the South Australian Department of Health, The Victorian Department of Human Services and Queensland Health for their financial support.
The APSF Annual Report 2005-06
02/01/2007
The Australian Patient Safety Foundation's Annual Report outlines the resources produced, presentations and papers given and projects undertaken for the financial year 2005-2006 .APSF's Anaesthesia Crisis Management Manual Second Edition (2006)
16/11/2006
Following upon the original 1996 publication of the 1st Edition of APSF's unique, data based collection of anaesthesia crisis management protocols based upon the first 2000 AIMS Anaesthesia incident reports, APSF is pleased to announce the release of the 2nd Edition of this Manual in November 2006.
This 2nd Edition is based upon the first 4000 AIMS Anaesthesia voluntary and anonymous incident reports submitted to APSF from practising anaesthetists in Australia and New Zealand. It contains stepwise protocols for the clinical management of 28 of the most commonly encountered acute clinical situations in anaesthesia practice (including paediatric anaesthesia). Special Appendices deal with adrenaline (and some other) critical dosage calculations and preparations.
The protocols have been 'internally validated' against those incident reports relating to each respective crisis where the management and/or outcome were identified as sub-optimal. Rapid access to each protocol is facilitated by attachable adhesive finger tabs. A web-based version of the protocols can be found here.
Requests for copies of this 2nd Edition, at a cost of Aus$20.00 (+ GST within Australia only) and plus postage for overseas orders only, are available by phone, fax, email or mail, via the following contacts:
Australian Patient Safety Foundation
GPO Box 400
Adelaide
South Australia 5001
Phone 61 (0)8 8222 5115
Fax: 61 (0)8 8232 6938
Email: bill.runciman@apsf.net.au
International Patient Safety Event Classification Stakeholder Consultation
17/08/2006
The World Health Organisation's World Alliance for Patient Safety is embarking upon a consultation process (the "Delphi survey") for the International Patient Safety Event Classification (IPSEC). This process is designed to obtain vitally important feedback on the proposed conceptual framework, concepts and terms.
Practitioners and other experts interested in patient safety are invited to participate in the Delphi survey to ensure we obtain wide-ranging input. Your participation is greatly valued and appreciated.
As a result of the feedback received through the Delphi Survey, the
IPSEC will be further revised. Field testing will commence in 2007. It is envisioned that the finalised version of the IPSEC will be available in 2008.
To access the Delphi survey visit: www.who-ipsec.org
WHO's Patient Safety Home Page can be accessed at:
APSF Summit 2006: From Understanding to Improvement
31/07/2006
The APSF 2006 Summit was held on:
Wednesday, 11 October 2006 at
Brookman Hall, University of South Australia
Speakers and Presentations:
- Prof Tjerk Van der Schaaf: Associate Professor of "Human Factors in Risk Control" Eindhoven University of Technology, The Netherlands and
Associate Professor of "Patient Safety Research"
Leiden University Medical Center Integration of Predictive and Retrospective risk analysis in healthcare -
Dr Jim Battles: Patient Safety Center for Quality Improvement and Patient Safety Agency for Healthcare Research & Quality (AHRQ), USA Where We Have Been? - Where are We Going? The Patient Safety Initiative in the
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Ms Anne Maddock: Director Quality Systems, Royal District Nursing Service (RDNS) South Australia,
(2005 Risk Manager of the Year) Enterprise wide risk management and improving safety and quality in health care -
Prof Penny Sanderson: Professor of Cognitive Engineering and Human Factors at the University of Queensland Supporting anaesthetist situation awareness: New tools, new challenges
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Dr Matthew Thomas: Program Director Human Factors and Safety Management Systems, University of South Australia Error Management in the Organisational Context
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Dr Annette Pantle: Director, Clinical Practice Improvement Projects, New South Wales, Clinical Excellence Commission From understanding to improvement • it’s child’s play. The Children’s Emergency Care Project in NSW
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Prof David Ben-Tovim: Director, Clinical Governance, Flinders Medical Centre Next Steps in Patient Safety; using lean thinking to build safety in, not inspect error out
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Dr Stuart Whittaker, CEO, Council for Health Service Accreditation of Southern Africa Managing Patients with HIV/AIDs Safely in
Delia Dent
Comparing the First and Last 2,000 Anaesthetic Incidents using AIMS
09/02/2006
The APSF receives anonymous paper-based incident reports from anaesthetists in Australia and New Zealand - the APSF has over 8,000 of these reports classfied and another 2,000 waiting classification. The Australian and New Zealand College of Anaesthetists has provided the APSF with a grant to "Compare the latest 2,000 incidents with the first 2,000 to track progress and devise safety strategies for new problems".
The last 2,000 incidents received by the APSF will be classified into the Advanced Incident Management System (AIMS). The types of clinical situations, their circumstances, contributing factors, minimising factors, monitors used, and outcomes will be compared to the first 2,000 incidents. The 30 articles published in the 1993 Anaesthesia and Intensive Care Symposium will be used as the basis of the comparison.
The project commenced in January 2006 and is expected to be completed by the end of the year.
Development of an Conceptual Framework for an International Patient Safety Classification
09/02/2006
The World Health Organisation's Alliance for Patient Safety has asked the APSF to lead the Working Group to develop the Conceptual Framework for an International Patient Safety Classfication. The Working Group will develop and define the high level concepts to ensure that the Classification
complies with the specifications required of all WHO Family of International Classifications.
Other members of the Workgroup include Thomas Perneger, Tjerk van der Schaaf, Richard Thomson, and JCAHO.
WHO has commissioned another group to identify a list of critical concepts to be included in the classification.
APSF Summit 2005: Innovations in Patient Safety for Clinical Leaders
28/09/2005
Aim: To present the latest information so you can implement quality and safety changes at your department or unit.
Wednesday May 18th 2005
Robson Lecture Theatre, Royal Adelaide Hospital
The APSF Summit was held in association with the South Australian Department of Health, the Royal Adelaide Hospital and the University of Adelaide.
The title of the Summit was Innovations in Patient Safety for Clinical Leaders. The Summit recognized that changes in patient safety are very difficult to make and sustain at the interface between clinician and patient. The aim of this Summit was to give clinicians practical ways to implement initiatives at departmental and ward level and to convert existing research into positive change.
The APSF would like to acknowledge the Australian Council of Safety and Quality in HealthCare, for providing support and for inviting Professor Cliff Hughes OAM.
Links to presentations are provided below:
- Mr Jim Birch, Chief Executive, South Australian Department of Health Opening address
- Prof Bob Helmreich, University of Texas Translating quality and safety evidence into meaningful change
- A/Prof Jeffrey Braithwaite, Centre for Clinical Governance, University of New South Wales Changing dysfunctional departments into teams ? navigating culture and politics
- Prof Bill Runciman, Australian Patient Safety Foundation Systems Change vs Clinical Autonomy: is there a way forward?
- Prof Drew Dawson, Centre for Sleep Research, University of South Australia New approaches to fatigue management
- Christy Pirone, Principal Consultant, Safety and Quality, SA Department of Human Services Toolkit: Using Root Cause Analysis techniques at departmental level
- Liz Fitzgerald, Patient Safety Manager, Queen Elizabeth Hospital Toolkit: Using Health Failure Effects Mode at departmental level
- Bernie Harrison, CPI Director, Royal North Shore Toolkit: Clinical Practice Improvement
- A/Prof Howard Galloway, Director of Medical Imaging, The Canberra Hospital Quality Use of Diagnostics (QUDI) Imaging Project
- James Edwards, Head Cardiothoracic Department, Royal Adelaide Hospital Application of Crew Resource Management Techniques in a Teaching Hospital Environment
- Prof Brendon Coventry, Department of Surgery, Royal Adelaide Hospital Hypothetical
Qualified Privilege / Statutory Immunity
28/09/2005
The Australian Incident Monitoring System (AIMS) was declared a Quality Assurance Activity in June 2001 by the Commonwealth Health Minister under Part VC of Section 124X of the Health Insurance Act 1973. The declaration is valid until June 2006. Protection under this legislation is intended to protect:
- The confidentiality of information that identifies information that becomes known solely as a result of the quality assurance activity; and
- people who participate in activities that involve the assessment or evaluation of the quality of health services provided by others.
The APSF is currently consulting with the Australian states and territories to consider the re-declaration of AIMS, and to ensure that all stakeholder's requirements are met.
Root Cause Analysis in Residential Aged Care
28/09/2005
The Quality Outcomes Branch of the Australian Department of Health and Ageing has appointed the Australian Patient Safety Foundation to undertake the Developing the Use of Root Cause Analysis in Residential Aged Care Project.
The aims of the project are to develop a resource that will:
- Identify and define adverse and sentinel events in the residential aged care context;
- Identify when RCA should be used in residential aged care;
- Increase focus on the clinical safety of residents in a residential aged care setting;
- Develop a tool kit on RCA in plain English that is easy to read and apply in residential aged care, to assist staff with the investigation and identification of processes that may be contributing to adverse health outcomes; and
- Identify training needs to implement RCA in residential aged care.
10 Tips for Better and Safer Care in Residential Aged Care
28/09/2005
The Quality Outcomes Branch of the Australian Department of Health and Ageing has contracted the APSF to produce a booklet "10 Tips Guide for Safer and Better Residential Aged Care." This builds on the work of the Australian Council for Safety and Quality in Health Care - in 2003, they produced a booklet titled "10 Tips for Safer Health Care".
The current project aims to adapt and broaden this publication for the aged care setting. It also aims to empower residents and their families by providing quality and easy to understand information on safer living in residential aged care facilities.
Currently, the draft Guide is subject to usability trials with consumer and carer groups.