Australian Commission on Safety and Quality in Health Care and its Role in Error Reduction - Term Paper Example

ACSQHC and its Role in Error reduction in Healthcare Student’s Name Institutional Affiliation ACSQHC and Its Role in Error Reduction in Healthcare The “Australian Commission on Safety and Quality in Health Care [ACSQHC]” is an entity that was established and officially recognised on the 1st of January 2006 under the “Public Governance, Performance and Accountability Act 2013” (ACSQHC, 2015; Australian Institute of Health and Welfare [AIHW], 2015). ACSQHC is supported by the Territorial, State and the Australian Governments. It is composed of three committees that include the Information Strategy, Private Hospital Sector, and Primary Care Committees that enable the incorporation of information strategy, private sector and primary care sector respectively (ACSQHC, 2015). ACSQHC also employs the advice of critical stakeholders such as health professionals and consumers (ACSQHC, 2015). The primary aim of the commission is to organise, support and inform the Australia's health system to enable the former deliver high-quality, safe care. Under the auspices of ACSQHC consumers and patients can experience better health care, the whole nation's population can have better outcomes in health, the productivity in healthcare can be improved, and the health system can be better sustained (Healthdirect Australia, 2012). The commission is tasked with coordinating and leading the enhancement of Australia's healthcare quality and safety through identification of policy directions and issues and recommendation of priority areas; quality and safety advocacy and knowledge dissemination; publicly reporting on the status of quality and safety and comparing this state against the national standards; recommendation of quality and safety national data sets; provision of relevant best practice advice to health ministries to propel improvement in quality and strategies’ implementation; and recommendation of nationally accepted standards relating to quality and safety improvement (AIHW, 2015). The roles of ACSQHC especially error reduction in health care shall be examined in detail in this paper. Standards of Safety and Quality ACSQHC has prescribed standards relating to quality and safety that address areas that include quality and safety governance in organizations dealing with health services, consumer partnership, healthcare-associated infection control and prevention, medication safety, matching procedure and identification of patients, clinical handover, pressure injuries prevention and management, recognition and response to clinical decline in an acute care setup, blood and blood products, falls prevention and forestalling of harms as a result of the falls (Department of Health Victoria, 2014). From these standards, patient safety emerges as a primary area of interest served by the ACSQHC and reduction or elimination of healthcare-related errors shall enhance safety and quality of care administered. Safety and Quality Governance Through this standard, a quality framework is established that enables the implementation of safe systems by health services. The standard requires that service centres for health should have a comprehensive governance system tasked with the establishment, fulfilment and frequent review of protocols, procedures and policies. To aid in this, health service centres are also required to have a quality management system in place that is responsible for monitoring and reporting on the quality and safety of the care given to patients and also guide in the implementation of any alterations in practice (Department of Health Victoria, 2014). A practical example of how this standard reduces errors in health is where a health institution introduces or fortifies existing policies such as recommending the preference of large packs over small gauze swabs to reduce misplacement or miscounting of surgical materials peri-operatively, and minimizations of change-overs of staff especially in surgical procedures that take long (Department of Health Victoria, 2014). Partnering with Consumers Under this standard ACSQHC advocates for health service organizations to involve consumers, carers, patients, families and other health professionals in the provision of health care as this has been demonstrated to decrease mortality, nosocomial infections, readmission rates, length of stay, and improve treatment adherence and functional status (ACSQHC, 2011). Therefore, the relevant stakeholders are supposed to be informed and familiarised with the quality and safety performance of the organization and be involved in the design of the delivery of care. For instance, hypersensitivity reactions a patient experiences are supposed to be well known to all individuals tasked with caring for patient to limit or avert a possible life-threatening anaphylactic reaction. Preclusion of Healthcare-associated Infections This standard requires healthcare systems to exhibit incorporation of risk management principles in ensuring the maintenance of clean, hygienic surroundings. Reusable medical devices, instruments and equipment should be reprocessed as per relevant standards (ACSQHC, 2011). Aseptic technique protocols are supposed to be in place and adhered to while transmission-based, and standard precautions for infection prevention should be implemented comprehensively. Medication Safety Medicines form a dominant treatment element in health care, and their use is also accompanied by more adverse events and errors that are experienced with any other health aspect (Roughead, Semple & Rosenfeld, 2013). In Australia, among the hospital admissions, admissions related to medication comprise 2%-3% with high prevalence been observed among certain subpopulations. For instance, among admissions concerning individuals aged at least 65 years, 20 to 30% have been reported to be medication related (Roughead, Semple & Rosenfeld, 2013). The significance of these medication-related admissions can be viewed in terms of cost that is estimated to be about $1.2 billion per year to the Australian economy. Mechanisms suggested by ACQSHC to enhance medication safety include the use of "electronic medication administration records [eMAR]" (Centre for health Systems and Safety Research [CHSSR], 2013a). eMAR enables tracking of dose omissions and reason for omission, enhanced medication administration timing, and lower risk of unwanted discontinuation of medication (CHSSR, 2013a). Besides, independent double checking of drug administration has been suggested to have an impact on the reduction of potentially hazardous medication errors. The efficacy of double checking in medication error reduction is enhanced if done by at least two people (CHSSR, 2013b). Also, automated dispensing systems have been suggested to decrease dose omission hence sustain the therapeutic efficacy of medications (CHSSR, 2013c). To enhance medication safety too, ACSQHC (2006) recommends avoidance of abbreviations and terms that are potentially dangerous and apply the prescribed principles informing consistency in prescribing. Identification of Patients and Matching of Procedures Wrong patient identification often leads to administration of the wrong care with major repercussions such as permanent functional losses and death. To avert such errors, this standard requires that the minimum number of approved patient identifiers should be three during registration, provision of care or therapy, patient transfer, clinical handover, or when generating discharge documentation (ACSQHC, 2011). The effectiveness of the systems established for identification and matching of patient needs should be regularly monitored and reviewed (ACSQHC, 2011). Clinical Handover This standard ensures that patient handover is done in a timely, structured and relevant manner with the necessary consultation that promotes the safety of the patient (ACSQHC, 2011). Without an efficient system in place to facilitate clinical handover, information transfer breakdown is possible resulting in otherwise avoidable adverse events. Policies or protocols governing clinical handover should be in place and well documented. The policies and the clinical handovers are supposed to be regularly reviewed, and improvements made based on the results observed (Department of Health Victoria, 2014). For instance, if it is identified that all ICU beds are fully occupied yet there is a patient requiring ICU care, procedures for managing such patients from a different department while engaging the ICU team should be in place. Blood and Blood Products The standard requires health service centres to have appropriate systems to inform the safe prescribing and utilization of blood or its products (ACSQHC, 2011). The relevant patient information including the patient's transfusion history and reasons why blood has been indicated shall also be documented. The health services centres are required to have systems that guide how blood and blood products shall be received, stored, transported or disposed of safely. The consumers, carers and patients should be informed of the benefits and risks accompanying use of blood products (ACSQHC, 2011; Department of Health Victoria, 2014). In case of an actual hazard, open disclosure should be applied in informing the consumers (ACSQHC, 2013). Managing and Prevention of Pressure Injuries, and Falls Prevention Hospitalised patients are at risk of pressure injuries, hence the need to have risk assessment framework to discern patients at pressure injuries' risks and falls' risk for timely preventive measures. Devices and equipment to aid in the prevention should be available, and evidence-based management measures should be available in the health service organization (ACSQHC, 2011). During patient movements, no lifting or “safe patient handling” policies should be available and adhered to prevent patient falls (Australia Nursing Federation, 2012). Recognition and Response to Deterioration in Clinical Condition in an Acute Care Setup Under this standard, ACSQHC (2011) recommends health service centres to have protocols, procedures, and policies as per the National Consensus Statement’s requirements. For example, care plans should be sufficiently detailed while policies regarding the identification of a deteriorating condition should be available and up-to-date. Physiological observations recorded should include triggers for care escalation in case of a deteriorating clinical condition. The clinical workforce should be able to use the available mechanisms for identifying a deteriorating condition and respond appropriately. Conclusion ACSQHC provides standards that guide the provision of care to patients in health service organizations. These organizations can modify the standards to suit the needs of the organization. Comprehensive implementation of the standards is instrumental in reducing errors in health care and prevent harm to the recipient of health care and maintain the integrity and efficacy of the organizations. References Australia Nursing Federation. (2012). No lifting 1. Canberra: ANF. Australian Commission on Safety and Quality Health Care. (2006). National terminology, abbreviations and symbols to be used in the prescribing and administering of medicines in Australian hospital. Darlinghurst: ACSQHC. Australian Commission on Safety and Quality in Health Care. (2011). National safety and quality health service standards September 2012. Sydney: ACSQHC. Australian Commission on Safety and Quality in Health Care. (2013). Australian open disclosure framework. Sydney: ACSQHC. Australian Commission on Safety andQuality in Health Care. (2015). Governance. Retrieved from http://www.safetyandquality.gov.au/about-us/governance/ Australian Institute of Health and Welfare. (2015). Safety and quality of health care. Retrieved from http://www.aihw.gov.au/safety-and-quality-of-health-care/ Centre for Health Systems and Safety Research. (2013a). Evidence briefings on interventions to improve medication safety. Electronic medication administration records. Australian Commission on Safety and Quality in Health Care, 1(5), 1-4. Retrieved from http://www.safetyandquality.gov.au/wp-content/uploads/2013/12/Evidence-briefings-on-interventions-to-improve-medication-safety-Electronic-medication-administration-records-PDF-1.35MB.pdf Centre for Health Systems and Safety Research. (2013b). Evidence briefings on Interventions to improve medication safety. Double-checking medication administration. Australian Commission on Safety and Quality in Health Care, 1(3). Retrieved from http://www.safetyandquality.gov.au/wp-content/uploads/2013/12/Evidence-briefings-on-interventions-to-improve-medication-safety-Double-checking-medication-administration-PDF-888KB.pdf Centre for Health Systems and Safety Research. (2013c). Evidence briefings on interventions to improve medication safety. Automated dispensing systems. Australian Commission o Safety and Quality in Health Care, 1(2). Department of Health Victoria. (2014). Supporting patient safety sentinel event program annual report 2011-12 and 2012-13. Melbourne, Vic.: Department of Health, State of Victoria. Healthdirect Australia. (2012). Australian commission on safety and quality in health care. Retrieved from http://www.healthdirect.gov.au/partners/acsqhc-australian-commission-on-safety-and-quality-in-health-care Roughead, L., Semple, S., Rosenfeld, E. (2013). Literature review: Medication safety in Australia. Sydney: Australian Commission on Safety and Quality in Healthcare. Read More