Safety and quality is our top priority Welcome to the second edition of the Digital Health Safety & Quality (S&Q) Bulletin. This Bulletin is a joint communique from eHealth NSW and the Clinical Excellence Commission (CEC) which provides systematic communication of digital health clinical safety and quality issues and risks to relevant NSW Health staff and communities.
We encourage you to make use of this Bulletin to learn, share and contribute to NSW Health’s efforts in providing world-class clinical care where patient safety is the first priority.
Dr Zoran Bolevich Adjunct Professor Michael C Nicholl
Chief Executive, eHealth NSW Chief Executive Chief Information Officer, NSW Health Clinical Excellence Commission |
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| Bypassing Nurse Witness – Strategies to minimise ‘Top Boxing’ (also known as Top Loading) |
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NSW Health Policy Directive PD2022_032 requires independent, second person checks to be performed prior to medication administration under certain circumstances and for specific medications or groups of medications. The Cerner Millennium eMR applications PowerChart and FirstNet are configured to support this policy requirement.
eMR applications provide for the documentation of both the primary staff member involved in the administration (recorded in the ‘performed by’ field) and the person performing the second check (recorded in the ‘witnessed by’ field) when a witness is required. The witness is prompted to confirm their identity and authenticate using their username and password.
Since implementation, circumstances where staff administering medications have bypassed system requirements for documenting second person checks have arisen. This practice, referred to as ‘Top Boxing’ or ‘Top Loading’ occurs when the primary staff member administering a medication uses a workaround, which permits administration without the need for a colleague to enter in their password, hence bypassing formal witness authentication.
A factsheet has been developed containing strategies to minimise the practice of Top Boxing which can be found here. A summary of the strategies is described below. |
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The recommended strategies are as follows:
Option 1 – This option describes the design which permits the ‘top-boxing’ workaround, with the recommendation that if this option is selected, an audit and feedback mechanism is established as part of an overarching governance process to monitor for instances where ‘Top Boxing’ is occurring. This design option supports downstream workflows and meets the policy requirements, provided that two independent staff members are involved in the medication administration process. An Audit Report is available and is based on work originally completed by Sydney Local Health District to support the auditing process. This report, EM010 – Meds Nurse Witness has been developed to allow staff to audit medication doses administered where the nurse witness sign off has not been completed as per the approved business process.
Option 2 – This design option prevents the logged-in user from being recorded as the medication administration witness, mitigating the practice of nursing staff bypassing the medication administration witness requirements by putting their credentials in the ‘witness’ field. This design option may be preferred in circumstances where an Local Health District (LHD) / Specialty Health Network (SHN) implements a forcing function in order to enforce policy, accepting more complicated downstream workflows.
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Seeking your feedback on the eHealth NSW Gap Analysis Tool to support the National Standards |
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The Gap Analysis Tool, developed to assist health service organisations in reviewing their implementation of the National Safety and Quality Health Service Standards (second edition), was released to all LHDs/SHNs across NSW in late 2021. The information included in the tool provides a brief description of: -
products and solutions across the eMR, eRIC and eMaternity
- reports available to support auditing
- examples of resources available from the pillars and the Ministry of Health
- links to webpages for further information
- evaluation via a survey.
The Gap Analysis Tool is a living document, and updates for Version 2 are in progress, as well as tools to support the National Safety and Quality Digital Mental Health Standards and the Aged Care Module and User Guide for Multi-Purpose Services. Your feedback is valuable in driving improvement of this tool as a resource for LHDs/SHNs. For access to the Gap Analysis Tool – click here. For access to the survey – click here. For more information on the National Safety and Quality Health Service Standards (NSQHS) (second edition) visit: Australian Commission on Safety and Quality in Healthcare. |
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| Principles to improve the safe use of Fixed Interval
Variable Doses |
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Fixed Interval Variable Dose (FIVD) is the method by which a medication is ordered by providing a variable dose range rather than a single set dose.
The dose to be administered is chosen by the clinician administering the medication, in response to pre-defined parameters such as pain score. While the dose is chosen from the range, the interval in which the chosen dose is administered remains fixed. An example of FIVD prescribing is HYDROmorphone 2-4 mg orally every four hours PRN (when required).
A factsheet, available here has been developed in response to an adverse event, which provides requirements for sites using electronic medication management (eMeds) systems regarding the use of FIVD when ordering medications. The factsheet includes principles to be applied to the use of FIVD and requirements to ensure patient safety, appropriate oversight and compliance with the Medication Handling Policy Directive PD2022_032 (Section 2.1 and Section 3.3.1).
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The recommended strategies are:
1. A review of the use of FIVD orders or order sets should be performed and use of FIVD avoided. Where the use of these order sets cannot be avoided, provide specific clinical criteria for nursing staff to support decisions on dose selection and monitoring.
2. Relevant LHD/SHN eMR, Clinical Governance and Drug and Therapeutics Committees and personnel should implement actions to ensure the requirements are met locally, and relevant staff, including Prescribers, Nursing Staff, Drug and Therapeutics Committees (DTCs) and eMeds Teams are made aware of their roles/responsibilities in fulfilling them, as described in the factsheet. |
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Improved visibility of vaccine and COVID-19 test status in HealtheNet and My Health Record |
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The Clinical Portal Summary View has been updated as shown in Figure 1 below. The patient demographic information is now included in an expandable header and the presentation of COVID-19 immunisation information has been updated.
The COVID-19 immunisation status is displayed, all immunisations are listed below (including the date of immunisation) and the most recent addition is the next immunisation due date. The landing page also includes COVID-19 pathology as a separate box, alerts (drawn from the discharge summaries), allergies and adverse reactions and all pathology visible on scrolling down.
The information is retrieved in real time from the Australian Immunisation Register (AIR) each time the Clinical Portal is opened.
Figure 1: The HealtheNet Clinical Portal Summary View |
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QIDS MatIQ – Helping to improve the safety and quality of maternity care |
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With initial funding from the Commonwealth Health Innovation Fund, the CEC in partnership with eHealth NSW, has established a maternity data intelligence system (QIDS MatIQ) to provide contemporaneous insight into the health and outcomes of mothers and babies across NSW public hospitals.
The vision is to provide clinicians data to monitor and improve the safety and quality of maternity care based on rich data extracts drawn from the eMaternity health information system.
The QIDS MatIQ system: - is the first near real-time, large scale maternity data system in Australia to be able to provide patient safety and outcome data to point-of-care clinicians and policy makers
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provides insights into maternity care that occurred as recently as last week
- covers 75% of NSW public hospitals (13 out of 15 LHDs/SHNs across NSW), with work in progress to bring onboard data from the remaining two LHDs that currently use Cerner Maternity
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allows clinicians to generate dashboards using the established QIDS framework, displaying insights through trends in maternity outcomes from public hospitals across NSW
- aligns with NSW Health’s Strategic Priorities of enhanced data mobilisation, enhanced population health intelligence and will inform clinicians so that they can continually improve their clinical practice and maternity outcomes.
Currently, weekly extracts are uploaded for use and work is underway to establish a Data Lake that will enable enhanced access to daily data uploads.
The QIDS MatIQ team, which includes medical, midwifery and data expertise, are engaging with clinicians and data managers across NSW LHDs to educate staff and support practice improvement projects in maternity care.
The benefits of having access to near real-time maternity data are already being realised – one notable example being the ability to track the uptake of COVID-19 vaccination in birthing mothers.
For more information about QIDS MatIQ click here |
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| Updates from the eHealth Safety & Quality Advisory Group (SQAG) and Safety & Quality Oversight Committee (SQOC) |
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There are two key Safety and Quality Governance Committees in eHealth NSW: -
Safety and Quality Oversight Committee (SQOC)
- Safety and Quality Advisory Group (SQAG).
These committees provide safety and quality advice, governance and support to eHealth NSW in identifying and managing clinical and patient safety issues related to the design, implementation or use of digital health tools across NSW Health. The committees actively monitor these processes using the risk register developed for SQOC. The SQAG escalates issues to SQOC.
For more information on the issues that have been discussed at recent meetings please click here If you would like further information about SQOC and SQAG please contact EHNSW-SafetyandQuality@health.nsw.gov.au |
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| A focus on the Single Digital Patient Record (SDPR) Program |
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The Single Digital Patient Record (SDPR) Program will deliver a holistic, statewide digital view of a patient’s medical records to better support clinical decision making and overall patient care. By integrating clinical information from multiple health systems into one single platform, clinicians will be able to access appropriate clinical information more easily at the point of care, with better systems that involve patients in their care. The Program will replace NSW Health’s multiple individual Electronic Medical Record (eMR), Patient Administration Systems (PAS) and Laboratory Information Management Systems (LIMS) with a single digital patient record platform for NSW Health. The Program is currently at the procurement stage which is progressing well and is expected to select an industry partner in 2022.
Clinical engagement has been undertaken with LHDs, SHNs, NSW Health Pathology, NSW Ministry of Health, and other pillar organisations to provide a foundation for collaboration and partnership across NSW.
As a transformational program significant to the whole of NSW, program governance is being incrementally established and is critical to the participation, transparency and quality of co-design and implementation with the clinical community. This will also enable improvements in the quality of health data resulting in increased opportunities for research and analytics. The Single Digital Patient Record will not only provide a basis for improved patient safety and quality of care, it will also accelerate NSW Health’s journey towards a digitally integrated health system and act as an enabler for successfully delivering the digital transformation which supports the Future Health roadmap. |
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Twelve essential Digital Health Safety & Quality Principles |
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The eHealth NSW Safety & Quality Principles describe the foundations needed to both provide safe and high-quality health ICT in healthcare and drive continuous improvement of our digital health environment.
The principles should be applied throughout the lifecycle of digital health ICT system development – from the business case, implementation and ongoing. Our digital systems should be evaluated against these principles to demonstrate where our products, solutions and systems are performing as expected to support our NSW Health clinical needs and to identify targets for improvement. |
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Using Improvement Science to enhance safety, quality and patient experience
Bulletin #1 featured the foundational level programs of the Safety & Quality Essentials Pathway. In this issue we highlight one of the intermediate level eLearning programs: Introduction to Improvement Science eLearning My Health Learning code: 378591148. More information can be found here and below: Time to complete Two to three hours. Who is this program for?
For all staff wishing to learn to improve the safety, quality, and patient experience of their service. What will you learn? The following modules will guide you through '14 steps' to plan, undertake and measure improvements, using a driver diagram. Learning objectives On completion of this program, you will be able to describe: - the model for improvement
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the importance of a multidisciplinary improvement team and project sponsor
- a range of ways to explore and measure the problem being improved (baseline data, flow chart, affinity diagram etc.)
- how to create and interpret a driver diagram
- steps in a Plan-Do-Study-Act (PDSA) cycle
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how to spread, scale up and sustain improvement initiatives
- how to interpret outcome, process and balancing measures using run charts, pareto charts and histogram.
Apply your learning as you move through the modules Download the companion workbook from the modules to apply your learning to plan your own local improvement. Local Manager approval is always required before commencing a local improvement. More information
Introduction to Improvement Science flyer here
Safety & Quality Essentials Pathway eLearning – Introduction to Improvement Science here |
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Residual risk: Cyber security is everyone’s responsibility NSW Health’s cyber security teams are seeing an increase in the frequency of sophisticated cyber-attacks. The most successful data breaches start with a phishing attack. Phishing is a type of social engineering attack often used to steal user data, including login credentials and credit card numbers. It occurs when a cyber-criminal tricks a victim into opening an email, instant message or text message.
Once users click on a link or open an attachment their device can easily be infected. An estimated 40% of ransomware attacks start through email. Please be on the lookout for phishing scams that attempt to trick you into performing tasks that reveal sensitive information and malicious attachments that can infect your computer when downloaded.
Actions we can all take to safeguard our data Information Security Services recommends we all take steps to protect our personal information in the following ways: - Wherever possible implement multi-factor authentication on your online accounts, for example, get an additional code sent to your phone by SMS before you can log into your account.
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Never respond to unsolicited phone calls, emails or text messages. Scammers impersonate government and business to convince people to act. If you aren’t sure, do your own research and make contact using publicly listed contact details for the organisation.
- Ensure anti-virus software is installed on all your online devices and is updated regularly.
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Complete the Cyber Security training modules specifically for NSW Health staff via My Health Learning by typing 'Cyber S.A.F.E.' in the search bar and complete the modules relevant to your role.
- Attend one of the free education courses offered by Cyber Security NSW. There are also specific courses for IT administrators and executives, who have unique needs in their roles.
Please email the Safety & Quality team from eHealth NSW’s Clinical Engagement and Patient Safety Directorate via EHNSW-SafetyandQuality@health.nsw.gov.au if you would like to share any successful strategies your organisation has used to address any of the issues presented in this bulletin. |
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Contacts
If you wish to contact the eHealth NSW S&Q team or the CEC, please do so via:
Clinical digital health solutions-related incidents and near misses involving patient care should be notified in ims+ (where relevant managers are asked to select 'eHealth NSW' in the ims+ field 'Other Health/Ambulance service that should be aware of this incident').
Digital health solutions technical incidents or difficulties should be reported in ServiceNow (via the SARA portal).
Share your thoughts about this Bulletin
We would love to hear your feedback about the content and future topics you would like us to cover in subsequent editions.
Please forward this message to your team if you feel it would be beneficial.
If you would like to be added to the Bulletin's distribution list or to unsubscribe, please send the eHealth NSW S&Q team an email via EHNSW-SafetyandQuality@health.nsw.gov.au. Copyright © 2022 eHealth NSW, all rights reserved. |
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