System solutions for medication safety: building quality, reducing

costs and improving safetyFriday 27th October 2017

WA. MEDICATION SAFETY SYMPOSIUM 2017

WA.CA Committee for Antimicrobials WA.DEP Drug Evaluation Panel WA.MSG Medication Safety Group WA.PDC Psychotropic Drugs Committee WA.TAG Therapeutic Advisory Group

What is RPH’s Vision?

“To be the one of the safest hospitals in Australia”

Why am I talking to you all about After-hours then?

The After-hours Space

SMR Data

BenchmarkingJanuary to June 2015

Overall HSMR - Data sourced from A-HED 2016

Weekend HSMR - Data sourced from A-HED 2016

Analysis of WeekendsWorkload Heavy/Very heavy 77%

Timeliness of review Occasionally 59%

Breaks Rarely/ Never 60%

Nurses happy? No… 45%

Happy for relative? No 56%

Service Improvement Team - RPH

Swiss Cheese?

Staff Shortages

Failure to monitor

Inexperience

Poor Communication

Service Improvement Team - RPH

Is this OK?

Whose fault is it?

What are we going to do about it?

Scenario #1

Scenario #2

CURRENT

SAFE

MODEL

Quality of Care Survey

Very good

Good Alright Poor Very poor

01020304050

How would you rate (in general) the quality of care after hours on your ward -

Post survey

n = 105

Very good

Good Alright Poor Very poor

01020304050

How would you rate (in general) the quality of

care after hours on your ward - Pre survey

n = 38 PRE

POST

What do Staff think of Afterhours?

BenchmarkingJanuary to June 2016

Overall HSMR - Data sourced from A-HED 2016

Weekend HSMR - Data sourced from A-HED 2016

Where to next?

Professor Patrick Hudson – Moving up the Culture Ladder (2001)

AcknowledgmentsSAFE Team• Dr Tim Bowles, Head of SAFE• Clinical Leads, Registrars, RMO’s of the SAFE Team – too numerous to name!• After Hours CNS’s and Nurse ManagerImplementation team• Nick May and Maggie BriggsExecutive• Dr Aresh Anwar • Dr Lesley Bennett• Ms Heather Kidd

And EspeciallyOur Patients, Ward Staff and Specialties!