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									The Australian Patient Safety Foundation




  Chairman’s Annual Report 2006-2007




                                           1
Contents
Introduction ............................................................................................................................... 3
Resources .................................................................................................................................. 5
Articles ...................................................................................................................................... 5
Presentations ............................................................................................................................. 6
Projects and other activities ...................................................................................................... 8
   World Health Organisation International Patient Safety Event Classification ..................... 8
   World Health Organisation Research Group ........................................................................ 8
   Accident Compensation Corporation .................................................................................... 8
   Anaesthetic Data ................................................................................................................... 9
   Coroners Data ....................................................................................................................... 9
   Flinders University Patient Safety Education Modules ........................................................ 9
   University of South Australia Patient Safety Lectures ......................................................... 9
   National Centre for Classification in Health (NCCH) Collaboration ................................... 9
   APSF Summit October 2006 .............................................................................................. 10
   Collaborations for Translating Evidence into Practice (CTEP) .......................................... 11
   University of South Australia Workshop: “Standards – Protocols, Algorithms: Human
   Factors and Work Practice in Healthcare” .......................................................................... 12
   Redesigning the Intellectual Property agreement with PSI ................................................ 12
   Reports to South Australian Department of Health ............................................................ 12
   Radiology Adverse Events Register Project ....................................................................... 12
   The Old Originals Meeting ................................................................................................. 13




                                                                                                                                               2
Introduction
In 2006-2007 the APSF continued to make a significant contribution to patient safety
research and innovation. The APSF has continued to be a key contributor to the
development of the International Classification for Patient Safety for the World Health
Organisation‟s Alliance for Patient Safety. This work will continue through the next year at
least. APSF President, Bill Runciman, is also the co-chair of one of the four World Health
Organisation Patient Safety Research streams “Patient Safety Research Methods and
Measures”.
There were two main publication highlights - Bill Runciman‟s co-authored book with Alan
Merry and Merrilyn Walton „Safety and Ethics in Healthcare‟ and the release of Version 2 of
the „Crisis Management Manual‟. The book was a huge project and my warm thanks go to
Klee Benveniste and Penny Boyce for their many hours of effort. John Williamson and Klee
Benveniste are also to be congratulated for their large contributions to the „Crisis
Management Manual‟.
A significant step taken by the APSF has been the start of the initiative “Collaborations into
Translating Evidence into Practice (CTEP)” which is a joint effort with the Joanna Briggs
Institute at the University of Adelaide and Royal Adelaide Hospital, and the Centre for
Clinical Governance Research at the University of New South Wales. These Collaboratives
are ambitious and innovative and represent a significant change in focus for the APSF,
however, we are confident that they will result in significant changes to the way medicine is
practiced and lead to further improvements in quality.




Back (from left): Jo Zwar, Penny Boyce, John Williamson, Kaye Dolman, Sandy Torr.
Front: Yvonne Harvey, Peter Hibbert, Bill Runciman, Klee Benveniste




                                                                                                 3
We farewelled, with our best wishes, John Williamson, who has been a source of great
wisdom, an inspiration, a mentor and a friend to us all. John retired in June and he leaves a
large legacy in patient safety as well as lifesaving, hyperbaric medicine, and marine
toxicology. John was a pioneer in culture change and information collection methodologies
about what went wrong in health care. His day to day contribution and advice will be sorely
missed.
Kaye Dolman joined the secretarial staff this year and she has worked excellently with
Penny and Bill to get papers and presentations out on time. Jo Zwar and Yvonne Harvey
have performed invaluable roles in classifying the anaesthesia and coroners‟ incidents.
Lastly I would like to thank the APSF Councillors for their contribution and guidance
throughout the year. The APSF Councillors and their representative organisations are:


Mrs Margaret Charlton               Consumer Representative

Mr Ray Clark                        Treasurer

A/Prof James Harrison               Australasian Faculty of Public Health Medicine

Dr Marie Heartfield                 Royal College of Nursing

Dr Sue Johanson                     Australasian College of Emergency Medicine
                                    Royal Australasian College of Surgeons (Vice
Prof Guy Maddern                    President)
                                    Australian and New Zealand College of
Dr Neil Maycock                     Anaesthetists
                                    Royal Australian and New Zealand College of
Dr David Morris                     Obstetricians and Gynaecologists

Prof Bill Runciman                  President

Dr David Tye                        Royal Australian College of General Practitioners




The activities of the APSF during the year are summarised below in the following section.




                                                                                                4
Resources
Runciman WB, Merry A, Walton M. Safety and Ethics in Healthcare. Aldershot: Ashgate,
2007 (Book – 334 pages).
Version 2 of the Crisis Management Algorithms was published. I would like to formally
acknowledge Astra Zeneca for their support in publishing the Manual. Extensive work has
also occurred to create a web-based version, accessed via the APSF website:
(http://www.apsf.com.au/crisis_management/Crisis_Management_Start.htm ).
The Manuals are being sold from the APSF at a cost-recovery price.


Articles
Braithwaite J, Westbrook J, Pawsey M, Greenfield D, Naylor J, Iedema R, Runciman WB,
Redman S, Jorm C, Robinson M, Nathan S, Gibberd R.
A prospective, multi-method, multi-disciplinary, multi-level, collaborative, social-
organisational design for researching health sector accreditation.
BMC Health Serv Res 2006 Sep 12; 6: 113.

Runciman WB, Williamson JAH, Deakin A, Benveniste KA, Bannon K and Hibbert PD.
An integrated framework for safety, quality and risk management: an information and
incident management system based on a universal taxonomy.
Qual Saf Health Care 2006; 15 Suppl 1: i82-i90.

Evans SM, Smith BJ, Esterman A, Runciman WB, Maddern G, Stead K, Selim P,
O‟Shaughnessy J, Muecke S, Jones S. Evaluation of an intervention aimed at improving
voluntary incident reporting in hospitals. Qual Saf Health Care 2007; 16(3): 169-175.

Williamson JA, Hibbert P, Benveniste K, Runciman WB.The development of a crisis
management manual for anesthetists and anesthesiologists.
Seminars in Anesthesia, Perioperative Medicine and Pain 2007; 26(3): 173-177.




                                                                                          5
Presentations

2006/7   Title                           Location                      Group

July     Learning From Things That       Melbourne      Australian Society of Anaesthetists /
         Go Wrong                                       Australian and New Zealand College
                                                                  of Anaesthetists

Aug      On Mankind, Machines &           Sydney        National Health Informatics Society of
         Mistakes                                               Australia Conference

Sept     Patient Safety Initiatives:     Brisbane          SimTech Healthcare Simulation
         Does Simulation Have a                                    Conference
         Role?

Oct      Walking the Talk –               Sydney           Clinical Governance Congress
         Integrated Governance in
                                                                  Panel Discussion
         Australian Healthcare

Oct      Safety, Quality & Ethics in     Adelaide           Third Year Medical students,
         Healthcare                                            University of Adelaide

Nov      Safety, Quality & Ethics in   Johannesburg,         Council for Health Service
         Healthcare                       Limpopo         Accreditation for Southern Africa
                                         Province,                   (COSASA)
                                         NorthWest
                                                                    Speaker tour
                                       Province, Free
                                           State;
                                        South Africa

Nov      Safety, Quality & Ethics in     Adelaide        Anaesthesia & Intensive Care Unit,
         Healthcare – What Should                            Royal Adelaide Hospital
         We Do?

Dec      The Scope of the Patient         Geneva          World Alliance for Patient Safety,
         Safety Research Agenda                             World Health Organization

Mar      Patient Safety Workshop       Bedford Park       Graduate Entry Medical Program,
                                                                Flinders University

Mar      Patient Safety                  Adelaide           Human Factors MSc Course,
                                                            University of South Australia

Apr      Patient Safety and AIMS            UK                Risk Management Team,
                                                            Royal Berkshire Hospital, UK

Apr      Patient Safety and AIMS         Scotland               Quality Improvement
                                                                      Scotland




                                                                                      6
Apr    Anaesthetic Incident             Orange, NSW     NSW Branch of the Australian and
       Monitoring                                      New Zealand College of Anaesthesia
       Anaesthetic Complications:
       Their Management and
       Prevention

May    Patient Safety Workshop –          Adelaide         University of South Australia
       Standards – Protocols –
       Algorithms
       Out of the Quagmire –
       translating evidence into
       practice
       Just Culture

May    Patient Safety Workshop            Darwin        Northern Territory Clinical School,
                                                        Graduate Entry Medical Program,
                                                               Flinders University

May    AIMS Anaesthesia: A               Melbourne     Australian and New Zealand College
       Comparative Analysis of the                      of Anaesthetists Annual Scientific
       First 2000 and the Most                                       Meeting
       Recent 1000 Incident reports

June   Introduction to the Concepts       Geneva           Meeting for the International
       of the International                              Classification for Patient Safety,
       Classification for Patient
                                                        World Alliance for Patient Safety,
       Safety
                                                          World Health Organization,
       Conceptual Framework with
       Semantic Relationships

June   Patient Safety Workshop          Bedford Park    Graduate Entry Medical Program,
                                                              Flinders University

June   Radiology Adverse Events           Adelaide      Royal Australian and New Zealand
       Register                                              College of Radiologists

June   Pilot findings from the           Melbourne     Quality Use in Diagnostics Imaging,
       Radiology Adverse Events                        Royal Australian and New Zealand
       Register (co-presentation                             College of Radiologists
       with A/Prof Howard
       Galloway)

June   An Overview of the problem         Sydney          Collaborations for Translating
       - an international perspective                        Evidence into Practice
       Setting Priorities




                                                                                      7
June    Regulation in Healthcare             Melbourne             Adverse Events Management
                                                                            Congress

June    Patient Safety and Risk               Adelaide         3rd Year Bachelor of Nursing Course,
                                                                    University of South Australia



Projects and other activities
World Health Organisation International Patient Safety Event Classification
In November 2005, the World Health Organisation's Alliance for Patient Safety asked the
APSF to lead the Working Group to develop the Conceptual Framework for an International
Classification for Patient Safety (ICPS). The Classification needed to comply 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 the Joint Commission for Accreditation of Healthcare Organisations.
The APSF submitted the Framework to WHO in June 2006. It was then subjected to a
worldwide Delphi process in the second half of 2006. On behalf of WHO, the APSF was
then involved in a qualitative analysis of the Delphi responses (700 of them) and we
provided written replies to all responses. The Conceptual Framework, in light of the
feedback from the Delphi process, was considerably revised and can be found on the WHO
website. The APSF has contributed significantly to the definitions and concepts within the
Classification. Information on the International Classification for Patient Safety can be found
at: http://www.who.int/patientsafety/taxonomy/en/


World Health Organisation Research Group
The World Alliance for Patient Safety has set up an expert working group to help the
Research Program of the WHO Alliance for Patient Safety deliberate on the opportunities
and directions for advancing the methods and measures for research on patient safety
worldwide, with special emphasis on data-poor environments.
Bill has been invited to lead to the Methods and Measures Working Group of the Research
Program together with Professor Ross Baker of Toronto University. This is one of the priority
objectives of the Research program led by Dr David Bates of the Brigham and Women‟s
Hospital in Boston, USA. http://www.who.int/patientsafety/research/en/
Various co-authored papers are currently in draft phase:


Accident Compensation Corporation
The Accident Compensation Corporation is a statutory authority in New Zealand providing
compensation to individuals suffering injuries derived from accidents. The APSF, as a
subcontractor to Health Outcomes International (HOI), a private firm based in Adelaide, won
the proposal to provide evaluation services for an Evaluation of the Treatment Injury
Legislation. The new legislation, which came into effect on 1 July 2005, simplifies the cover
criteria and claims processes for injuries arising from treatment and eliminates the fault
element in relation to medical misadventure, replacing it with an entitlement based on a
direct causal link between a personal injury and treatment by a health professional.


                                                                                              8
The overall purpose of the evaluation is to indicate progress towards achieving the intent of
the treatment injury legislation, and identify any modifications that might assist in achieving
this intent (including any legislative, policy, operational or other modifications).
The project will run over a period of four years.


Anaesthetic Data
The APSF was successful in an application to the Royal Australian and New Zealand
College of Anaesthetists to classify anaesthetic incidents into the AIMS with the aim of
comparing results from these incidents to the first 2000 incidents which were published in
the 1993 Anaesthesia and Intensive Care Symposium.
Anaesthetic nurses have been employed to classify the incidents and as of June 2007, 1200
incidents had been classified.
The findings from the data were presented at the Australian and New Zealand College of
Anaesthetists Annual Scientific Meeting in May 2007 by Bill Runciman.


Coroners Data
A nurse/classifier has been employed to classify incidents sourced from the National
Coroners Information System (NCIS). As of June 2007, about 120 incidents had been
classified. This data will be compared with data from other sources such as medical record
reviews and incident monitoring.

Flinders University Patient Safety Education Modules
Flinders University designed a Patient Safety Module for their final (4 th) year medical
students and asked the APSF to contribute to its development. Three modules were
successfully run (each 1.5 days), with APSF staff (Bill and John) giving lectures.
Our congratulations and thanks to Martin Basedow from the Clinical Governance Unit at
Flinders Medical Centre for all his organisation and hard work organising the modules.


University of South Australia Patient Safety Lectures
John continued to give lectures on the concepts of patient safety to final year nurses at the
University of South Australia.


National Centre for Classification in Health (NCCH) Collaboration

The National Centre for Classification in Health (NCCH) is the Australian centre of
excellence in health classification theory and an expert centre in coding systems. NCCH
clinical terminologies and statistical classification development underpin health information
knowledge systems. The NCCH works with Australian Institute of Health and Welfare
(AIHW) to fulfil its function as World Health Organization (WHO) Collaborating Centre for
Classification of Disease in Australia and the western Pacific region.

The APSF developed an alliance with the NCCH that was invaluable during the
development of the ICPS Conceptual Framework and the re-development of the
classification for version 4 of the AIMS software.




                                                                                                  9
APSF Summit October 2006
The APSF 2006 Summit “From Understanding to Improvement” was held on Wednesday, 11
October 2006 at Brookman Hall, University of South Australia. Delegates heard three
prominent international speakers presenting research and updates on the current state of
patient safety in The Netherlands, the United States, and South Africa as well as national
patient safety and human factors experts from Australia.
The presentations were:
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 United States
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
Dr Matthew Thomas: Program Director Human Factors and Safety
Management Systems, University of South Australia Error Management in the
Organisational Context
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
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
Dr Stuart Whittaker, CEO, Council for Health Service Accreditation of Southern
Africa Managing Patients with HIV/AIDs Safely in South Africa
Delia Dent, Patient Safety International, Costing Adverse Events by linking Incident
Monitoring and Clinical Costing Systems
All the presentations can be accessed from the APSF website.
We would like to thank Christy Pirone and the South Australian Department of Health and
Matthew Thomas and the University of South Australia for their generous support of the
Summit.




                                                                                              10
Collaborations for Translating Evidence into Practice (CTEP)
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.
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. We 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 presenters were:
Professor Bill Runciman: An Overview of the problem - an international perspective and
Setting priorities: evidence from the USA, UK and Australia
Professor Ian Scott: An Australian perspective
Professor 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
Presentations can be accessed at the APSF website.
The rationale and proposal that was presented to the meeting was:
   The percentage of patients who receive recommended or expected care for a range of
    common conditions is unacceptably low (this primarily relates to the quality dimension of
    appropriateness).
   The rate of improvement is unacceptably slow.
   The cost effectiveness of many conventional change management strategies is
    questionable (the use of opinion leaders, outreach visits and tailored interventions,
    breakthrough strategies, inter-professional education didactic lectures). Interactive
    workshops, audit and feedback and the use of guidelines show some promise.
    However, there are cultural barriers to the use of guidelines by both senior and junior
    doctors.
   For many clinical conditions, substantial bodies of evidence exist for appropriate care.
    Furthermore, in many cases, these bodies of evidence have been transformed into
    guidelines.
   This is a proposal for clinician-led reform by the development, if necessary, or the
    adoption, of agreed guidelines for common conditions, and converting these into national
    clinical standards which may be implemented using tools developed by practising
    clinician.
A Coogee Charter was agreed by the meeting delegates:


                                                                                               11
“We want to work together as clinicians to make healthcare safer for our patients by
ensuring that effective collaboration and change management tools and techniques support
agreed evidence based standards that are put into clinical practice and show measurable
improvement by 2010.”
The next steps:
      A website will be established.
      An operational committee comprising Professor Jeffrey Braithwaite, Professor Alan
       Pearson from the Joanna Briggs Institute, and Professor Bill Runciman from the
       Australian Patient Safety Foundation will be established.
      Key bodies in Australian health care will be invited onto a reference committee.
      Links will be established with international organisations such as world federations of
       professional societies, the World Health Organisation and the International Society
       for Quality in Healthcare with a view to promoting this process in other countries and
       disseminating evidence-based standards from any country which develops them to
       other countries in the world.


University of South Australia Workshop: “Standards – Protocols, Algorithms:
Human Factors and Work Practice in Healthcare”
The APSF co-hosted a workshop with the University of South Australia called “Standards –
Protocols, Algorithms: Human Factors and Work Practice in Healthcare”. Dr Jan Davies,
from the Calvary Health Service in Canada, was the special guest presenter.


Redesigning the Intellectual Property agreement with PSI
The APSF has a 20 year licence with its commercial subsidiary Patient Safety International
(PSI) that enables PSI to use market, develop and sell AIMS. There were a number of
obligations that were difficult for both organisations to fulfil and PSI were concerned that it
limited the potential for capital raising.
The IP agreement between the two organisations was re-designed and signed during the
year.


Reports to South Australian Department of Health
The APSF was commissioned to analyse the statewide AIMS database for thematic reports,
based on equipment incidents, contaminated equipment, patient identification, and gas
embolism.
The APSF was also commissioned to write a section of the Patient Safety Report for 2005-
2006.


Radiology Adverse Events Register Project
The Radiology Adverse Events Register (RAER) www.raer.org is a project funded by the
Royal Australian and New Zealand College of Radiologists (RANZCR) Quality in Use in
Diagnostic Imaging (QUDI) Program. The QUDI Program is funded through a grant from
Australian Government Department of Health Ageing (DoHA).

QUDI has commissioned the Australian Patient Safety Foundation (APSF) and Patient
Safety International (PSI) to undertake the project.


                                                                                              12
This project is designed to undertake systematic data collection and analysis of adverse
incidents and discrepancies in radiology to inform quality improvement and patient safety.
The register went live in June 2006. A number of institutions have agreed to participate in
a 12 month pilot.

A pilot report of about 130 incidents was provided to the College and was well received.
Efforts are continuing to include other data sources such as medico-legal reports.


The Old Originals Meeting
The Old Originals Meeting was organised by John Williamson, and held in the offices of the
Australian and New Zealand College of Anaesthetists (ANZCA), and funded by the APSF.
The meeting was recognition of the incredible efforts of a small group of anaesthetists in
forming the APSF and commencing the Anaesthetic Incident Monitoring Study, a national
anonymous collection of incidents with the objective of finding out things that went wrong.
The Study continues to this day. It was also a time to reflect what had been achieved in
anaesthesia safety and further goals that need to be set.
The presentations:
Dr Wally Thompson, President, Australian and New Zealand College of
Anaesthetists: Introduction and Welcome. “AnLet: Feedback in Early Anaesthesia
Training.”
Mr Peter Hibbert, Manager, Australian Patient Safety Foundation
       ”A Welcome from APSF with a précis overview of its activities.”
Dr Pat Mackay: “The road to ‘retirement’: The role of AIMS”
Dr John Williamson:        “AIMS Anaesthesia – some recent findings”
Professor John Russell: “Looking backward - wrong drugs reviewed.”
Dr Noel Cass: “Keep it simple.”
Dr Craig Morgan: “Tools for personal anaesthetic audit.”
Dr Bob Webb:         “More computers, more information, more safety??”
Professor Ross Holland:         “Oximetry in ECT - 20 years on.”
Dr Rod Westhorpe: "Anaesthesia Safety - some historical tidbits"
Dr Lyn Currie:       “Pesky women!”
General discussion: So where does anaesthesia safety go from here?
The APSF would like to thank ANZCA for their generous use of their offices and assistance
in organising the day. Our thanks are also extended to Dr Wally Thompson, College
President, and Dr Mike Richards, College CEO, for their attendance. …
The Old Originals were presented with life membership of the APSF.




                                                                                              13
The Old Originals Meeting:
Back (from left): John Williamson, Ross Holland, Craig Morgan, John Russell, Bob Webb,
Peter Hibbert, Rod Westhorpe, Noel Cass, Lyn Currie, Pat Mackay, Wally Thompson




Bill Runciman
APSF Chairman
Date 11th November 2007




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