NSQHSS 4 - 10

• Document No.

• Department

• Conducted on

  Date

• Prepared by

• Personnel

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

• Department audited specialty - bed numbers - services provided

Governance and systems for medication safety

• 4.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide medication safety systems

• 4.1.2 Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines

• 4.2.1 The medication management system is regularly assessed

• 4.2.2 Action is taken to reduce the risks identified in the medication management system

• 4.3.1 A system is in place to verify that the clinical workforce have medication authorities appropriate to their scope of practice

• 4.3.2 The use of the medication authorisation system is regularly monitored

• 4.3.3 Action is taken to increase the effectiveness of the medication authority system

• 4.4.1 Medication incidents are regularly monitored, reported and investigated

• 4.4.2 Action is taken to reduce the risk of adverse medication incidents

• 4.5.1 The performance of the medication management system is regularly assessed

• 4.5.2 Quality improvement activities are undertaken to reduce the risk of patient harm and increase the quality and effectiveness of medicines use

Documentation of patient information

• 4.6.1 A best possible medication history is documented for each patient

• 4.6.2 The medication history and current clinical information is available at the point of care

• 4.7.1 Known medication allergies and adverse drug reactions are documented in the patient clinical record

• 4.7.2 Action is taken to reduce the risk of adverse reactions

• 4.7.3 Adverse drug reactions are reported within the organisation and to the Therapeutic Goods Administration

• 4.8.1 (D) Current medicines are documented and reconciled at admission and transfer of care between healthcare settings

Medication management processes

• 4.9.1 Information and decision support tools for medicines are available to the clinical workforce at the point of care

• 4.9.2 The use of the information and decision support tools are regularly reviewed

• 4.9.3 Action is taken to improve the availability and effectiveness of information and decision support tools

• 4.10.1 Risks associated with secure storage and safe distribution of medicines are regularly reviewed

• 4.10.2 Action is taken to reduce the risks associated with storage and distribution of medicines

• 4.10.3 The storage of temperature-sensitive medicines is monitored

• 4.10.4 A system that is consistent with legislative and jurisdictional requirements for the disposal of unused, unwanted or expired medications is in place

• 4.10.5 The system for disposal of unused, unwanted or expired medications is routinely monitored

• 4.10.6 Action is taken to increase compliance with the system for storage, distribution and disposal of medications

• 4.11.1 The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed

• 4.11.2 Action is taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines

Continuity of medication management

• 4.12.1 A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines

• 4.12.2 A current and comprehensive list of medicines is provided to the patient and/or carer when concluding an episode of care

• 4.12.3 A current comprehensive list of medicines is provided to the receiving clinician during clinical handover

• 4.12.4 Action is taken to increase the proportion of patients and receiving clinicians that are provided with a current comprehensive list of medicines during clinical handover

Communicating with patients and carers

• 4.13.1 (D) The clinical workforce provides patients with patient-specific medicine information, including medical treatment options, benefits and associated risks

• 4.13.2 (D) Information that is designed for distribution to patients is readily available to the clinical workforce

• 4.14.1 (D) An agreed medication management plan is documented and available in the patient’s clinical record

• 4.15.2 (D) Information on medicines is provided to patients and carers in a format that is understood and meaningful

• 4.15.2 (D) Action is taken in response to patient feedback to improve medicines information distributed by the health service organisation to patients

Identification of individual patients

• 5.1.1 Use of an organisation-wide patient identification system is regularly monitored

• 5.1.2 Action is taken to improve compliance with the patient identification matching system

• 5.2.1 The system for reporting, investigating and analysis of patient care mismatching events is regularly monitored

• 5.2.2. Action is taken to reduce mismatching events

• 5.3.1 Inpatient bands are used that meet the national specifications for patient identification bands

Processes to transfer patient care

• 5.4.1 A patient identification and matching system is implemented and regularly reviewed as part of structured clinical handover, transfer and discharge processes

Processes to match patients and their care

• 5.5.1 A documented process to match patients and their intended treatment is in use

• 5.5.2 The process to match patients to any intended procedure, treatment or investigation is regularly monitored

• 5.5.3 Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation

Governance and leadership for effective clinical handover

• 6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored

• 6.1.2 Action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols

• 6.1.3 Tools and guides are periodically reviewed

Clinical handover processes

• 6.2.1 The workforce has access to documented structured processes for clinical handover that include: preparing for handover, including setting the location and time whilst maintaining continuity of patient care organising relevant workforce members to participate being aware of the clinical context and patient needs participating in effective handover resulting in transfer of responsibility and accountability for care

• 6.3.1 Regular evaluation and monitoring processes for clinical handover are in place

• 6.3.2 (D) Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers

• 6.3.3 Action is taken to increase the effectiveness of clinical handover

• 6.3.4 The actions taken and the outcomes of local clinical handover reviews are reported to the executive level of governance

• 6.4.1 Regular reporting, investigating and monitoring of clinical handover incidents is in place

• 6.4.2 Action is taken to reduce the risk of adverse clinical handover incidents

Patient and carer involvement in clinical handover

• 6.5.1 (D) Mechanisms to involve a patient and, where relevant, their carer in clinical handover are in use

Governance and systems for blood and blood product prescribing and clinical use

• 7.1.1 Blood and blood product policies, procedures and/or protocols are consistent with national evidence- based guidelines for pre- transfusion practices, prescribing and clinical use of blood and blood products

• 7.1.2 The use of policies, procedures and/or protocols is regularly monitored

• 7.1.3 Action is taken to increase the safety and appropriateness of prescribing and clinically using blood and blood products

• 7.2.1 The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed

• 7.2.2 Action is taken to reduce the risks associated with transfusion practices and clinical use of blood and blood products

• 7.3.1 Reporting on blood and blood product incidents is included in regular incident reports

• 7.3.2 Adverse blood and blood product incidents are reported to and reviewed by the highest level of governance in the health service organisation

• 7.3.3 Health service organisations participate in relevant haemovigilance activities conducted by the organisation or at state or national level

• 7.4.1 Quality improvement activities are undertaken to reduce the risks of patient harm from transfusion practices and the clinical use of blood and blood products

Documenting patient information

• 7.5.1 A best possible history of blood product usage and relevant clinical and product information is documented in the patient clinical record

• 7.5.2 The patient clinical records of transfused patients are periodically reviewed to assess the proportion of records completed

• 7.5.3 Action is taken to increase the proportion of patient clinical records of transfused patients with a complete patient clinical record

• 7.6.1 Adverse reactions to blood or blood products are documented in the patient clinical record

• 7.6.2 Action is taken to reduce the risk of adverse events from administering blood or blood products

• 7.6.3 Adverse events are reported internally to the appropriate governance level and externally to the pathology service provider, blood service or product manufacturer whenever appropriate

Managing blood and blood product safety

• 7.7.1 Regular review of the risks associated with receipt, storage, collection and transport of blood and blood products is undertaken

• 7.7.2 Action is taken to reduce the risk of incidents arising from the use of blood or blood product control systems

• 7.8.1 Blood and blood product wastage is regularly monitored

• 7.8.2 Action is taken to minimise wastage of blood and blood products

Communicating with patients and carers

• 7.9.1 Patient information relating to blood and blood products, including risks, benefits and alternatives, is available for distribution by the clinical workforce

• 7.9.2 (D) Plans for care that include the use of blood and blood products are developed in partnership with patients and carers

• 7.10.1 (D) Information on blood and blood products is provided to patients and carers in a format that is understood and meaningful

• 7.11.1 (D) Informed consent is undertaken and documented for all transfusions of blood or blood products in accordance with the informed consent policy of the health service organisation

Governance and systems of the prevention and management of pressure injuries

• 8.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools

• 8.1.2 The use of policies, procedures and/or protocols are regularly monitored

• 8.2.1 An organisation-wide system for reporting pressure injuries is in use

• 8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries

• 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation

• 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries

• 8.3.1 Quality improvement activities are undertaken to prevent pressure injuries and/or improve the management of pressure injuries

• 8.4.1 Equipment and devices are available to effectively implement prevention strategies for patients at risk and plans for the management of patients with pressure injuries

Preventing pressure injuries

• 8.5.1 An agreed tool to screen for pressure injury risk is used by the clinical workforce to identify patients at risk of a pressure injury

• 8.5.2 The use of the screening tool is monitored to identify the proportion of at-risk patients that are screened for pressure injuries on presentation

• 8.5.3 Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation

• 8.6.1 Comprehensive skin inspections are undertaken using an agreed assessment tool and documented in the patient clinical record for patients at risk of pressure injuries

• 8.6.2 Patient clinical records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments

• 8.6.3 Action is taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries

• 8.7.1 Prevention plans for all patients at risk of a pressure injury are consistent with best practice guidelines and are documented in the patient clinical record

• 8.7.2 The effectiveness and appropriateness of pressure injury prevention plans are regularly reviewed

• 8.7.3 (D) Patient clinical records are monitored to determine the proportion of at-risk patients that have an implemented pressure injury prevention plan

• 8.7.4 (D) Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan

Managing pressure injuries

• 8.8.1 An evidence-based wound management system is in place within the health service organisation

• 8.8.2 Management plans for patients with pressure injuries are consistent with best practice and documented in the patient clinical record

• 8.8.3 Patient clinical records are monitored to determine compliance with evidence-based pressure injury management plans

• 8.8.4 Action is taken to increase compliance with evidence-based pressure injury management plans

Communicating with patients and carers

• 8.9.1 (D) Patient information on prevention and management of pressure injuries is provided to patients and carers in a format that is understood and is meaningful

• 8.10.1 (D) Pressure injury management plans are developed in partnership with patients and carers

Establishing recognition and response systems

• 9.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide recognition and response systems

• 9.1.2 Policies, procedures and/or protocols for the organisation are implemented in areas such as: measurement and documentation of observations escalation of care establishment of a rapid response system communication about clinical deterioration

• 9.2.2 Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems

• 9.2.3 Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable

• 9.2.4 Action is taken to improve the responsiveness and effectiveness of the recognition and response systems

Recognising clinical deterioration and escalating care

• 9.3.1 (D) When using a general observation chart, ensure that it: is designed according to human factors principles includes the capacity to record information about respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness graphically over time includes thresholds for each physiological parameter or combination of parameters that indicate abnormality specifies the physiological abnormalities and other factors that trigger the escalation of care includes actions required when care is escalated

• 9.3.2 Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations recorded in agreement with their monitoring plan

• 9.3.3 Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient’s monitoring plan

• 9.4.1 Mechanisms are in place to escalate care and call for emergency assistance

• 9.4.2 Use of escalation processes, including failure to act on triggers for seeking emergency assistance, are regularly audited

• 9.4.3 Action is taken to maximise the appropriate use of escalation processes

Responding to clinical deterioration

• 9.5.1 Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols

• 9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed

• 9.6.1 The clinical workforce is trained and proficient in basic life support

• 9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practice advanced life support

Communicating with patients and carers

• 9.7.1.(D) Information is provided to patients, families and carers in a format that is understood and meaningful. The information should include: the importance of communicating concerns and signs/symptoms of deterioration, which are relevant to the patient’s condition, to the clinical workforce local systems for responding to clinical deterioration, including how they can raise concerns about potential deterioration

• 9.8.1 (D) A system is in place for preparing and/or receiving advance care plans in partnership with patients, families and carers

• 9.8.2 (D) Advance care plans and other treatment-limiting orders are documented in the patient clinical record

• 9.9.1 (D) Mechanisms are in place for a patient, family member or carer to initiate an escalation of care response

• 9.9.2 (D) Information about the system for family escalation of care is provided to patients, families and carers

• 9.9.3 (D) The performance and effectiveness of the system for family escalation of care is periodically reviewed

• 9.9.4 (D) Action is taken to improve the system performance for family escalation of care

Governance and systems for preventing falls

• 10.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines (where available) and incorporate screening and assessment tools

• 10.1.2 The use of policies, procedures and/or protocols is regularly monitored

• 10.2.1 Regular reporting, investigating and monitoring of falls incidents is in place

• 10.2.2 Administrative and clinical data are used to monitor and investigate regularly the frequency and severity of falls in the health service organisation

• 10.2.3 Information on falls is reported to the highest level of governance in the health service organisation.

• 10.2.4 Action is taken to reduce the frequency and severity of falls in the health service organisation

• 10.3.1 Quality improvement activities are taken to prevent falls and minimise patient harm

• 10.4.1 Equipment and devices are available to implement prevention strategies for patients at risk of falling and management plans to reduce the harm from falls

Screening and assessing risks of falls and harm from falling

• 10.5.1 A best practice screening tool is used by the clinical workforce to identify the risk of falls

• 10.5.2 Use of the screening tool is monitored to identify the proportion of at-risk patients that were screened for falls

• 10.5.3 Action is taken to increase the proportion of at-risk patients who are screened for falls upon presentation and during admission

• 10.6.1 A best practice assessment tool is used by the clinical workforce to assess patients at risk of falling

• 10.6.2 The use of the assessment tool is monitored to identify the proportion of at-risk patients with a completed falls assessment

• 10.6.3 Action is taken to increase the proportion of at-risk patients undergoing a comprehensive falls risk assessment

Preventing falls and harm from falls

• 10.7.1 Use of best practice multifactorial falls prevention and harm minimisation plans is documented in the patient clinical record

• 10.7.2 The effectiveness and appropriateness of the falls prevention and harm minimisation plan are regularly monitored

• 10.7.3 Action is taken to reduce falls and minimise harm for at-risk patients

• 10.8.1 Discharge planning includes referral to appropriate services, where available

Communicating with patients and carers

• 10.9.1 (D) Patient information on falls risks and prevention strategies is provided to patients and their carers in a format that is understood and meaningful

• 10.10.1 (D) Falls prevention plans are developed in partnership with patients and carers