Patient safety notification system
Guideline number: QH-HSDGDL-032-3:2013
Effective date: 1 March 2024
Review date: 1 March 2027
Supersedes: Version 2.0
On this page:
- Purpose
- Scope
- Reporting patient safety issues that have statewide impacts
- Actioning a patient safety notification
- Supporting and related documents
- Definition of terms
- Approval and implementation
- Version control
1. Purpose
This Guideline describes Queensland Health’s process for managing and responding to potentially statewide patient safety issues and risks, through the development and distribution of patient safety notifications issued by the Department of Health.
2. Scope
This Guideline applies to Queensland Health employees, agents, volunteers, contractors, consultants and managed service providers working for the Divisions within the Department of Health, Agencies and Business Units and for the Hospital and Health Services (HHSs) (including Visiting Medical Officers).
3. Reporting patient safety issues that have statewide impacts
3.1 HHSs have commonalities in the use of equipment, processes and interactions in the provision of health care. Therefore, an opportunity exists to prevent incidents of patient harm and risk across the public health system by sharing locally identified issues which have potential statewide implications.
3.2 HHSs should have local processes for identifying and managing patient safety issues/risks. The local processes should include a specific line management responsibility for considering the potential for the identified issue/risk to also apply to other HHSs.
Examples of potential statewide patient safety issues that may be identified locally include: medical device or consumable failures or malfunctions and unclear labels or instructions for use on medical devices.
3.3 Potential statewide patient safety issues/risks must be reported to the Patient Safety and Quality Branch (PSQ). They may be reported by telephone or email using the contact details below. Where there is uncertainty about whether an issue/risk should be reported, please telephone the PSQ for advice:
PSQ contact details for locally identified potential patient safety issues/risks:
Phone: 3328 9430
Email: Patient_Safety_Notifications@health.qld.gov.au
4. Actioning a patient safety notification
4.1 The PSQ, Clinical Excellence Queensland, Department of Health co-ordinates a patient safety notice system that assesses potential statewide patient safety issues/risks with key stakeholders. Where an issue/risk is identified, the PSQ will advise HHSs of the identified risk, lessons learned from the analysis or investigation and any recommendations for local action to address potential patient harm.
4.2 The four-tiered patient safety notification system is based on clearly identifiable categories (alert, notice, advisory or communique) which indicate the suggested importance for local prioritisation and management:
- Patient safety alerts are colour coded RED and are issued regarding patient safety matters requiring mandatory, immediate attention and urgent action.
- Patient safety notices are colour coded AMBER and issued regarding potential patient safety issues that are semi-urgent and requiring local risk assessment to inform appropriate action.
- Patient safety advisories are colour coded BLUE for lower urgency, lower risk notifications requiring local risk assessment to inform appropriate action.
- Patient safety communiques are colour coded GREEN and are issued to disseminate patient safety information to ensure lessons learned from local incident analyses/investigations (and a variety of other sources) are shared across the state.
4.3 Patient safety notifications will be distributed by email from PSQ to the generic HHS email accounts. HHSs should have local processes for ensuring the timely distribution of all patient safety notifications to relevant staff within the HHS.
4.4 HHSs should have local processes for prioritising and actioning patient safety notifications that include clear roles, responsibilities and timeframes for those responsible to action notifications.
4.5 HHSs should have a process that provides a coordinated response to patient safety notifications across all facilities within an HHS through Chief Executive/Executive Director of Medical Service/Director of Clinical Governance to PSQ.
4.6 Where requested in the patient safety notification, the HHS should submit a response through its Chief Executive/Executive Director of Medical Services/Director of Clinical Governance to the designated contact address, within the designated timeframe, using the feedback template which will be supplied with the patient safety notification.
5. Supporting and related documents
Authorising Health Service Directive
Patient Safety Health Service Directive QH-HSD-033:2014
Legislation
Therapeutic Goods Act 1989 (Cth)
Competition and Consumer Act 2010 (Cth)(previously Trade Practices Act 1974)
Radiation Safety Act 1999 - s.45
Radiation Safety Regulation 2010
Radiation Safety (Radiation Safety Standards) Notice 2010
Work Health and Safety Act 2011
Work Health and Safety Regulation 2011
Plant Code of Practice 2005
Resources
Queensland Health’s alerts, advisories and communiques are available at: https://qheps.health.qld.gov.au/psu/alerts
Accreditation references
Australian Commission on Safety and Quality in Health Care, National Safety and Quality Health Service Standards 2nd Edition; 2017 Clinical Governance Standard.
6. Definition of terms used in this guideline
Term | Definition / explanation / details |
Patient safety notification | The term patient safety notification is a generic term used in this Guideline to refer to a range of different types of patient safety notifications that include patient safety alerts, patient safety notices, patient safety communiqués, |
Patient safety alert | Aims to quickly disseminate information to HHSs regarding a safety matter requiring immediate mandatory attention and urgent action. It specifies mandatory action to be undertaken by HHSs, assigns responsibility for action and feedback as well as timeframes in which the action should occur. |
Patient safety notice | Aims to inform HHSs regarding potential quality and safety issues requiring semi-urgent risk assessment at the local level to determine appropriate action with regards to incidents. The patient safety notice will specify that HHSs must undertake a risk assessment. It also recommends action to be taken. |
Patient safety advisory | Aims to inform HHSs regarding potential quality and safety issues of lower urgency and lower risk, requiring risk assessment at the local level to determine appropriate action. The patient safety advisory will suggest HHSs undertake a risk assessment. It also recommends action to be taken. |
Patient safety communiqué | A patient safety communique aims to disseminate quality and safety information to HHSs to ensure lessons learned from local, statewide, national and international sources are shared across Queensland Health in a pro-active manner. |
Patient safety risk | An event or circumstance that has led to or could potentially lead to patient harm. |
Risk | The potential for an event to have an impact on individuals and/or organisations. It is measured in terms of likelihood and consequence. |
Statewide patient safety issues/risks | A locally identified patient safety issue/risk that may also apply to other HHS and may result in patient harm; for example; equipment failure or product fault potentially resulting in death. |
7. Approval and implementation
Guideline custodian
Executive Director, Patient Safety and Quality, Clinical Excellence Queensland, Department of Health
Approving officer
Deputy Director General, Clinical Excellence Queensland, Department of Health
Approval date: 27 February 2024
Effective from: 1 March 2024
8. Version control
| Version | Date | Prepared by | Comments |
|---|---|---|---|
| 1.0 | 01/08/2013 | HSCI | New Guideline |
| 2.0 | 31/01/2021 | PSQIS |
Updated email addresses, phone numbers and the name Patient Safety Unit, to Patient Safety and Quality Improvement Service. Minor clerical amendments in line with the Queensland Health Editorial style guide 2019. Amendment to flow of document. Additional guidance on co-ordination of response to patient safety notifications across facilities within a HHS |
3.0 | 01/03/2024 | PSQ | Updated the name to Patient Safety and Quality Branch (PSQ). Inclusion of additional category of patient safety notification to include a Patient Safety Advisory. Described the definition of a Patient Safety Advisory. |