The internal audit of clinical areas: a pilot of the internal audit methodology in a health service emergency department.

QUALITY PROBLEM OR ISSUE: Governing bodies of health services need assurance that major risks to achieving the health service objectives are being controlled. Currently, the main assurance mechanisms generated within the organization are through the review of implementation of policies and procedures and review of clinical audits and quality data. INITIAL ASSESSMENT: The governing bodies of health services need more robust, objective data to inform their understanding of the control of clinical risks. CHOICE OF SOLUTION: Internal audit provides a methodological framework that provides independent and objective assurance to the governing body on the control of significant risks. IMPLEMENTATION: The article describes the pilot of the internal audit methodology in an emergency unit in a health service. An internal auditor was partnered with a clinical expert to assess the application of clinical criteria based on best practice guidelines. EVALUATION: The pilot of the internal audit of a clinical area was successful in identifying significant clinical risks that required further management. LESSONS LEARNED: The application of an internal audit methodology to a clinical area is a promising mechanism to gain robust assurance at the governance level regarding the management of significant clinical risks. This approach needs further exploration and trial in a range of health care settings.

Preventing critical failure. Can routinely collected data be repurposed to predict avoidable patient harm? A quantitative descriptive study.

OBJECTIVES: To determine whether sharing of routinely collected health service performance data could have predicted a critical safety failure at an Australian maternity service. DESIGN: Observational quantitative descriptive study. SETTING: A public hospital maternity service in Victoria, Australia. DATA SOURCES: A public health service; the Victorian state health quality and safety office-Safer Care Victoria; the Health Complaints Commission; Victorian Managed Insurance Authority; Consultative Council on Obstetric and Paediatric Mortality and Morbidity; Paediatric Infant Perinatal Emergency Retrieval; Australian Health Practitioner Regulation Agency. MAIN OUTCOME MEASURES: Numbers and rates for events (activity, deaths, complaints, litigation, practitioner notifications). Correlation coefficients. RESULTS: Between 2000 and 2014 annual birth numbers at the index hospital more than doubled with no change in bed capacity, to be significantly busier than similar services as determined using an independent samples t-test (p<0.001). There were 36 newborn deaths, 11 of which were considered avoidable. Pearson correlations revealed a weak but significant relationship between number of births per birth suite room birth and perinatal mortality (r2 =0.18, p=0.003). Independent samples t-tests demonstrated that the rates of emergency neonatal and perinatal transfer were both significantly lower than similar services (both p<0.001). Direct-to-service patient complaints increased ahead of recognised excess perinatal mortality. CONCLUSION: While clinical activity data and direct-to-service patient complaints appear to offer promise as potential predictors of health service stress, complaints to regulators and medicolegal activity are less promising as predictors of system failure. Significant changes to how all data are handled would be required to progress such an approach to predicting health service failure.

Prostate cancer: the new evidence base for diagnosis and treatment.

Although prostate cancer (PC) has a significant mortality, there is debate regarding the utility of PC screening. This debate continues as major studies investigating the value of population-based screening have yet to be concluded. Despite this, there is increasing evidence from preliminary reports from these series, as well as numerous others relating to outcome prediction for PC, that early detection leads to improved outcomes and a decrease in the burden of metastatic disease on our healthcare system. PC is rarely symptomatic until it has metastasised to bone and because of this PSA-based screening remains the only widely available and reliable method of diagnosis for organ-confined disease. There is now compelling evidence to show that: 1. Cancers diagnosed by screening are more likely to be early stage, when most can be cured by a number of different treatment options. 2. The maximum benefits of screening are for men aged 50-70 years. Older men have a greater chance of a clinically insignificant cancer being diagnosed for which treatment is not necessary. 3. The familial risks of PC are well recognised. In particular, men with one or more first-degree relatives already diagnosed with the disease should be actively encouraged to undergo screening. 4. Modern histopathological assessment of fine core needle biopsies of the prostate allows for the likely behaviour of cancer present to be accurately predicted. Changes that mimic those of malignancy can be confidently identified, so these cases are no longer incorrectly diagnosed. These improvements mean that now most men aged 50-70 years diagnosed with PC will have clinically significant cancers that require treatment.

Unreported clinical deterioration in emergency department patients: a point prevalence study.

BACKGROUND: Formal processes for recognising and responding to deteriorating emergency department (ED) patients are variable despite features of the ED context that may increase the risk of unrecognised or unreported clinical deterioration. The aim of this study was to determine the frequency and nature of unreported clinical deterioration in emergency care. METHODS: A prospective, exploratory descriptive design was used. Data were collected during nine point prevalence surveys (PPS) from 1 May to 30 June 2009 at an urban district hospital in Melbourne Australia. Patients present in ED cubicles during the PPS (n=186) were included in the study. RESULTS: Unreported clinical deterioration occurred in 12.9% of patients (n=24/186). Unreported clinical deterioration was more common when: (i) patients aged ≥65 years comprised >50% of patients within the ED; (ii) occupancy of the resuscitation, monitored or general adult cubicles was >50%; and (iii) the proportion of patients requiring treatment within 30 min (Australasian Triage Category 1, 2 or 3) was ≤50% of the total ED population. CONCLUSIONS: Unreported clinical deterioration is an important quality indicator of emergency care. The effect of the collective ED patient group on the frequency and nature of adverse events for individual ED patients is poorly understood and warrants further investigation.

Unipedicle TRAM flap procedures are associated with symptoms of pelvic floor dysfunction in women: a case control study.

HYPOTHESIS: Chronic conditions that cause raised intra-abdominal pressure, such as obesity, chronic cough and constipation are risk factors for pelvic floor dysfunction (PFD). We hypothesise that unipedicle transverse rectus abdominis musculocutaneous flap (UTRAM flap) for reconstruction following mastectomy for breast cancer increases the risk of PFD. AIM: The aim of this study is to assess if there is increased risk of pelvic floor dysfunction associated with UTRAM flap reconstruction compared to controls. METHOD: 39 patients who had UTRAM flaps for breast reconstruction following mastectomy for breast cancer between year 1997 to 2004 were recruited as cases. They were matched by age with 36 controls, who have had breast cancer but not U TRAM flap reconstruction as part of their treatment. Validated questionnaires (Pelvic floor distress inventory PFDI-20) were completed by study participants, and demographic data were also collected. Mixed effect analysis of variance was used to assess for statistical difference in the mean PFDI-20 scores, adjusted by age, parity, BMI and history of gynaecological surgery. RESULTS: The case group has significantly higher mean PFDI-20 score than the control group, 13 (3-29) vs 5.5 (1-11), MH odds ratio 1.8 (1.1-2.8), p value=0.02. CONCLUSION: Women who have undergone U TRAM flap reconstruction appeared to have more symptoms of PFD, compared to women who did not have the procedure. It is likely that the reduction in volume of abdomen, following surgery leads to an increase in intra-abdominal pressure (IAP) which predisposes these women to PFD. Future work to assess changes in IAP is proposed.

Medication errors in ED: Do patient characteristics and the environment influence the nature and frequency of medication errors?

BACKGROUND: Medication safety is of increasing importance and understanding the nature and frequency of medication errors in the Emergency Department (ED) will assist in tailoring interventions which will make patient care safer. The challenge with the literature to date is the wide variability in the frequency of errors reported and the reliance on incident reporting practices of busy ED staff. METHODS: A prospective, exploratory descriptive design using point prevalence surveys was used to establish the frequency of observed medication errors in the ED. In addition, data related to contextual factors such as ED patients, staffing and workload were also collected during the point prevalence surveys to enable the analysis of relationships between the frequency and nature of specific error types and patient and ED characteristics at the time of data collection. RESULTS: A total of 172 patients were included in the study: 125 of whom patients had a medication chart. The prevalence of medication errors in the ED studied was 41.2% for failure to apply patient ID bands, 12.2% for failure to document allergy status and 38.4% for errors of omission. The proportion of older patients in the ED did not affect the frequency of medication errors. There was a relationship between high numbers of ATS 1, 2 and 3 patients (indicating high levels of clinical urgency) and increased rates of failure to document allergy status. Medication errors were affected by ED occupancy, when cubicles in the ED were over 50% occupied, medication errors occurred more frequently. ED staffing affects the frequency of medication errors, there was an increase in failure to apply ID bands and errors of omission when there were unfilled nursing deficits and lower levels of senior medical staff were associated with increased errors of omission. CONCLUSIONS: Medication errors related to patient identification, allergy status and medication omissions occur more frequently in the ED when the ED is busy, has sicker patients and when the staffing is not at the minimum required staffing levels.