Publication Index

CEC Publications

This is an index of general publications issued by the Clinical Excellence Commission. Publications are ordered alphabetically by topic, then by date.

Chartbook

Chartbook on Safety and Quality in Health Care in NSW 2009
Chartbook on Safety and Quality in Health Care in NSW 2010

The 2010 Chartbook includes a new chapter on Cancer Services (surgical volumes); and expands certain existing indicators (e.g. Population Health, Ambulance Services, Aboriginal Health and CEC initiatives in safety and quality). Again, new presentation formats have been introduced, this time to portray the data by the new local health districts.

Download PDF ~1.9mb
Chartbook on Safety and Quality in Health Care in NSW 2009
Chartbook on Safety and Quality in Health Care in NSW 2009

The 2009 Chartbook includes two new chapters on Patient Experience and Cancer Services (incidence and mortality); and expands certain existing indicators (e.g. Population Health, Mental Health Services, Ambulance Services, Aboriginal Health and CEC initiatives in safety and quality). New presentation formats have also been debuted.

Download PDF ~1.5mb
Chartbook on Safety and Quality in Health Care in NSW 2008
Chartbook on Safety and Quality in Health Care in NSW 2008

The 2008 Chartbook offers information on access to services; the appropriateness, effectiveness and safety of care; efficiency of service provision and consumer participation. It provides coverage of many types of services from child and maternal care, to mental health care and emergency services. It spans clinical areas such as cardiac care and neonatal services.

Download PDF ~1.5mb

Chartbook on Safety and Quality in Health Care in NSW 2007
Quality of Healthcare in NSW: A Chartbook 2007
(Revised Edition)

The Chartbook aims to make the NSW health system better and safer for patients.

Chartbook users please note an errata has been published. A revised edition of The Chartbook is available which incorporates the changes in the errata. For those with printed copies of Chartbook 2007, please print the errata page and keep it with the document.

Download PDF ~1.0mb


Chartbook 2007 Errata PDF ~36kb
How to Use The Chartbook PDF ~24kb

Emergency Departments

Service Quality and Communication in Emergency Department Waiting Rooms - Report
Service Quality and Communication in Emergency Department Waiting Rooms - Report

In 2009-10, the Clinical Excellence Commission funded research into service quality and communication in emergency department waiting rooms. The research team was comprised of staff from Southern Cross University with applied skills and knowledge in organisational communication, culture, history, structures and operations.

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Incident Management

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Incident Management in the NSW Public Health System
Six-monthly Report Series

These reports provide information on clinical incidents reported in the NSW health system.

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Analysis of first year of IIMS data Annual Report 2005-2006

This inaugural report provides an overview of the first complete year of statewide IIMS data, with a focus on clinical notifications. The report provides valuable insights into the nature and number of clinical incident notifications occurring in the system, and a platform for sustainable clinical improvements.

Download PDF ~1.1mb


Medication Safety

KIDCAP child resistant packaging information sheet
Child-Resistant Packaging - KIDCAP

Some medicines can cause serious harm, even death, if they are accidentally ingested by infants or children. Child-resistant packaging is designed to limit or delay access to medicines. A warning code, KIDCAP, has been added to i.Pharmacy systems in NSW. This information sheet provides pharmacy staff with information about the warning code and the provision of child resistant packaging.

Download PDF ~345kb

Mortality Review

NSW Mortality Review: The Way Forward
NSW Mortality Review: The Way Forward
July 2014

Patients admitted to NSW hospitals receive a high standard of care by dedicated professionals who are committed to quality and safety. This compendium has been compiled to provide direction and supporting resources for clinicians and managers within the NSW health system in relation to mortality review. Its aim is to facilitate a standardised approach to mortality review.

Download PDF ~1.2Mb

Patient Safety

CEC's Patient Safety Program
Patient Safety Report
Clinical supervision at the point of care

Clinical Supervision is frequently defined as a formal process of professional support and learning which enables individual clinicians (medical, nursing and allied health professionals) to develop knowledge and competence and assume responsibility for their own practice (Cutcliffe & Butterworth 2001). The focus of this report, however, is point of care supervision.

Download PDF ~676kb
CEC's Patient Safety Program
Patient Safety Report
Fractured Hip Surgery in the Elderly

The information in this report has been de-identified and analysed in accordance with Incident Information Management System (IIMS) datasets and where relevant, the classification sets used by the CEC and the Root Cause Analysis Review Sub-committees.

Download PDF ~780kb
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Patient Safety Research
A comparative analysis of eight Inquiries in six countries

This is a report of eight Inquiries into alleged poor health care. Three are from Australia: from Perth (King Edward Memorial Hospital), Melbourne (Royal Melbourne Hospital) and Sydney (Campbelltown-Camden). The remainder are from Scotland (Glasgow's Victoria Infirmary), England (Bristol Royal Infirmary), Slovenia (Celje Hospital), New Zealand (Southland DHB) and Canada (Winnipeg Health Sciences Centre).

Download PDF ~1.10mb
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Patient Safety Research
A review of the technical literature

This monograph has been prepared as part of a program of research on safety and quality undertaken for the Clinical Excellence Commission (CEC) in New South Wales by the Centre for Clinical Governance Research at University of New South Wales. It seeks to assess the patient safety literature and suggest a way forward for clinical teams in providing safer healthcare.

Download PDF ~804kb
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Patient Safety Research
Giving A Voice To Patient Safety In New South Wales

This monograph is the final in a series prepared by the Centre for Clinical Governance Research at the University of New South Wales for the Clinical Excellence Commission. The aim of the series is to shed light on what has become one of the most important questions in health care practice and management: what do we know about patient safety and what we can do about it?

Download PDF ~768kb

Quality Improvement

Clinician's Guide to Quality and Safety
Clinician's Guide to Quality and Safety

Our Clinician's Guide to Quality and Safety is targeted at frontline clinicians starting in quality and safety improvement. It outlines the foundations of quality and safety and provides an introduction into essential quality and safety tools.

Download PDF ~2.0MB

Quality Systems Assessment

2014 QSA NSW Statewide Report
Quality Systems Assessment (QSA) Safer Systems Better Care, 2014 report

The 2014 cycle of the QSA reviewed local safety and quality systems relating to health care teams, nutrition care, pressure injury prevention and wound management systems. An online self-assessment received 1,800 responses from clinical teams and was followed up with more than 260 improvement conversations at multiple organisation levels.

Download PDF ~ 1.3Mb
2013 QSA NSW Statewide Report
Quality Systems Assessment (QSA) Safer Systems Better Care
2013 report

Results from the 2013 process reaffirmed the strength of systems to support patient safety and clinical quality in NSW. The report identifies seven recommendations for proactive local improvement that the CEC will support by working with local teams and system-level partners.

Download PDF ~ 1.63Mb

Special Committee Investigating Deaths under Anaesthesia

Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) case reviews booklet 2015
Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) case reviews booklet 2015

This booklet presents the learning points of reviewed cases where the patient died within 24 hours of anaesthetic administration in a NSW hospital. The case profiles highlight the importance of pre-operative assessment and planning, supervision of junior staff, team work, situational awareness, clinical judgement and decision making as key competencies for safe anaesthetic administration.

Download PDF ~982kb
Activities of the Special Committee Investigating Deaths Under Anaesthesia (SCIDUA) 2015 Special Report
Activities of the Special Committee Investigating Deaths Under Anaesthesia (SCIDUA)
Special Reports

The reporting of anaesthesia-related deaths has helped ensure the high quality and safety of anaesthetic administration. These reports provide the evidence for demonstrating the safety and risk of anaesthesia.


TOP 5

TOP 5: Improving the Care of Patients with Dementia 2012 - 2013 Research Report
TOP 5: Improving the Care of Patients with Dementia
2012 - 2013 Research Report (Phase 1)

This TOP 5 research study indicates that the use of a low cost, patient based communication strategy for patient care is associated with significant improvements in patient outcomes, safety, carer experience and staff satisfaction while providing potential cost savings to health services.

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TOP 5: Improving the Care of Patients with Dementia 2014 - 2015 Research Report
TOP 5: Improving the Care of Patients with Dementia
2014 - 2015 Research Report (Phase 2)

This research study examined the use of TOP 5 in transitions of care between hospital, Residential Aged Care Facilities (RACFs) and community services. The results indicate that TOP 5 is a valuable communication strategy that can be used during transitions of care to improve patient safety, staff and carer satisfaction.

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