Hospitals, Adverse Event Reporting

I seek leave to make a brief explanation before asking the Minister for Aboriginal Affairs and Reconciliation, representing the Minister for Health, a question regarding adverse event reporting in hospitals.

The Hon. J.M.A. LENSINK: It is estimated that some 16.6 per cent of hospital admissions result in an adverse event and that 60 per cent of errors could have been prevented.

Costs associated with such errors are estimated at $4.5 billion nationally. I understand that a strategy that can assist with this particular problem is the Australian incident monitoring system (AIMS) that has been developed but that, within that system, only eight ‘sentinel adverse events’ will be recorded.

My questions are:

1. What other risk management and benchmarking measures does the government have in place to improve hospital systems?

2. How much capital and recurrent funding has the South Australian government allocated to AIMS?

3. How many hospitals have so far implemented the new system?

4. Of those hospitals that have not yet implemented the system, how many are at the training stage and how many remain at the initial implementation stage?

5. What organisation is being used to provide this training and how will its quality and consistency be monitored?

6. When does the minister expect the system to be fully operational and data being reported in all South Australian hospitals?

7. What action is the Health Commission taking to ensure adverse event reporting by hospitals in South Australia?

8. Since AIMS is a voluntary system, will the government instigate other regulatory requirements, making its use compulsory, to ensure the safety of patients and improved quality of health care across the state?

The Hon. T.G. ROBERTS (Minister for Aboriginal Affairs and Reconciliation): I will refer those questions to the Minister for Health and bring back a reply.

Wednesday 15 October 2003

In reply to Hon. J.M.A. LENSINK (17 September).

The Hon. T.G. ROBERTS: The Minister for Health has provided the following information:

1. In line with international literature and approaches, and the strategic directions of the Australian Council for Safety and Quality in Health Care, the Department of Human Services (DHS) is promoting the establishment of a safety culture that focuses on the improvement of systems as a sustainable approach to improving safety and quality in health care.

DHS has taken a multi-faceted approach to the prevention of adverse events and the improvement of patient safety. Specific initiatives include:

the Patient Safety Framework’, which outlines a statewide multi-faceted approach to improving patient safety within South Australian hospitals and health services. Major features of this framework include:

centralised incident reporting structures;

the implementation of root cause analysis in the investigation of incidents, with shared learning from this process;

notification of sentinel events;

monitoring of quality performance indicators;

communication of safety and best practice issues via the Safety and Quality website [email protected];

statewide and patient population specific patient satisfaction surveys;

a commitment to involving the consumer in the quality and safety agenda;

the establishment of the South Australian Hospitals Safety and Quality Council, and its committee structure (the Metropolitan Clinical Subcommittee and the Country Subcommittee), to provide leadership for improving the quality of hospital care in South Australia and to support national efforts in promoting systemic improvements in the safety and quality of health care;

the provision of education and training in relation to safety and quality;

funding and support of multiple patient safety improvement projects; and

implementation of the OACIS Clinical Information System to improve patient safety through the availability of timely and complete information across hospital sites.

2. The government has allocated approximately $1 million to the central rollout of the Advanced Incident Monitoring System (AIMS) for the 2003-04 financial year, and approximately $780 000 for ongoing use and support of the centralised statewide system for the 2004-05 financial year.

AIMS is a computerised system for collecting, classifying, analysing and learning about things that go wrong in health care.

AIMS has undergone continuous improvement since it was first developed in 1989, and has been progressively developed to accommodate the increasingly complex requirements of its users.

AIMS allows the capture of incident information from a wide variety of sources. Incidents that are collected in AIMS are not limited to sentinel events but any event or circumstance that could have, or did, cause unintended harm, suffering, loss or damage. That is, all adverse events and near misses’ can be reported using the same system.

3. In 1997-98 DHS purchased AIMS on behalf of the public health system, and sites were encouraged to install the system and monitor incidents. Most sites joined over the following two years, with the exception of the small metropolitan hospitals and some country hospitals. AIMS+ is the current version in use in most South Australian hospitals and is a stand alone’ version of the software.

Newer versions of the software have been subsequently developed, which allow greater flexibility in access to, and use of, the system across the state. A new version is currently in the final stages of beta testing prior to wider release. At present there are four country hospitals and five metropolitan hospitals that have been involved in implementing the new system across a number of wards in order to trial the new software. The trials have proved successful and it is planned to roll out the system to all public hospitals in the state over the next twelve months. In the interim, existing users of the AIMS+ system will continue to use that.

4. In addition to the four country and five metropolitan hospitals that are trialing the new software, three more metropolitan hospitals have undergone initial training in the new system ready for the statewide rollout. Information sessions have been held in each of the seven country regions. Further planning for the connection of country sites is required as part of regional implementation plans covering information technology, resource and training issues, which are being prepared by each region in conjunction with DHS.

5. The Australian Patient Safety Foundation (APSF), based in South Australia, developed the AIMS software. Patient Safety International (PSI), a subsidiary company of APSF, is responsible for the provision of client support and training services.

The training is being undertaken using a train-the-trainer approach, whereby nominated people from each organisation are given detailed training in each component of the system and are provided with extensive training materials prepared by PSI for use in their own organisations. PSI will also provide data quality checks and help desk support for consistent use of the system.

6. Planning has proceeded on the basis of having the new centralised AIMS system fully operational and having public hospitals connected by a target date of 1 July 2004. This is subject to further consultation with individual hospitals and preparation of regional implementation plans.

7. There are several actions that DHS is taking to ensure adverse event reporting by public hospitals in South Australia:

committing to the funding of the new AIMS software system for an initial two year period until the end of the 2004-05 financial year, including the provision of centralised support;

the inclusion of the reporting of adverse events in health care service agreements with country and metropolitan hospitals;

the requirement to separately report de-identified details of eight listed sentinel events directly to DHS;

the promotion of safety and quality no-blame’ cultures to reduce fear and uncertainty and encourage reporting of adverse events; and

reviewing the barriers to reporting.

8. The APSF classification system for incident reporting has recently been adopted by the state Quality Officials Forum of the Australian Council for Safety and Quality in Health Care for national use. The inclusion in health service agreements of requirements for health services to report on incidents by type as reported in AIMS and to notify sentinel events makes the systems of reporting essentially compulsory. However, making reporting compulsory does not ensure improved safety and quality. The identification of the barriers to reporting, and facilitating the desire and processes for reporting, are more powerful in ensuring improvements. This is in line with DHS’s approach to developing a safety culture that will promote the inherent need to report. Additionally, incident reporting, while valuable, is just one of the tools that are used to identify areas for quality improvement. A multi-faceted approach to addressing safety and quality in healthcare provides a more comprehensive framework for improvement.