EMER SITE CHAMPION NEWS November, 2015

Edition 9

Welcome!

In This Issue

The EMER Steering group has been busy looking into innovative ways we can promote safety in our EDs. See below “Coming soon” for an update. We would also like to take this opportunity to congratulate Dr Kim Hansen in winning first prize for her poster submitted at the recent ACEM ASM held in Brisbane this month. Outstanding effort , Kim! Her poster can be seen on pages 2 and 3 of this newsletter. We hope you enjoy this edition of the Site Champion Newsletter and we continue to thank you for your efforts in promoting ED incident reporting. Keep up the good work!!!

Coming soon ! We are excited to announce that we are currently working towards consumer reporting via the EMER website (http://www.emer.org.au/). Should any of your patients identify an incident, or wish to report a near miss, very soon you will be able to encourage them to report via EMER. All incidents and near misses reported will be addressed by members of the EMER Steering group and ACEM. The more information we can gather on what is going wrong in our EDs, from both clinician and consumer perspectives, the better we can identify what needs doing to make EDs safer for all. An email will be sent out to you all to let you know that consumer reporting is up and running. For now…..watch this space!!

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Welcome

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Coming soon!

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EMER poster

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How can I encourage reporting into EMER?

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This month’s tip for site champions

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EMER Database update

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Meet the Steering Group

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Publications of interest

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Safety alert

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Incident of the month

Another exciting announcement is the inclusion of Safety Alerts specific to ED’s. These will be widely distributed through the College website, newsletters, social media and of course through emer.org.au.

What does this mean? Keep reading to find out.

The EMER website is: www.emer.org.au

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The EMER Steering Group wish you all a happy Christmas season and wish you all the best for a safe and prosperous new year.

ACEM ASM Poster - slide 1

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ACEM ASM Poster - slide 2

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How can I encourage reporting into EMER? On recruitment as a Site Champion you were sent resources to assist you in the role of implementing EMER in your organisation. Don’t forget these and additional materials, are always available online at http://www.emer.org.au/get-involved.html or on request from [email protected]. In addition to these resources, each month we will endeavour to offer you a handy tip to assist you in maintaining interest in staff reporting into EMER.

This month’s tip for site champions When we talk about incident reporting we all tend to immediately think the things that have gone wrong but we forget to take into account the things that could have gone wrong - the near misses and good saves. These “potential” incidents can be just as informative as the things that actually did occur. Actual incidents, near misses and good saves can all be reported into EMER.

EMER Database Update We currently have 238 incidents in the EMER database and 31 Site Champions across Australia and New Zealand. Thank you to those of you who have been conscientiously entering incidents. Remember, ALL incidents are valued —near misses and “good saves” included. So keep reporting! The more incidents we have, the more information we have to work with to make positive

Meet the Steering Group With increased communication between the EMER Steering Group and Site Champions we would like to take this opportunity to each month introduce one of the EMER Steering Group members to you so you can put a face to the name”! This month it is with great pleasure we introduce you to Dr Matthew Shepherd. I am an Emergency Physician and the DEMT in Tamworth NSW, where I moved with my wife and (at that stage) 2 children from Darwin in January 2006; we now also have a “local” in the family. I have found it very difficult to explain Tamworth to people over the years (possibly because of my loyal Maroon blood) but have come to love the town and surrounds, the people and the ease of everyday life. I never feel like an endangered species on my bicycle, never have to share a lane at the local Olympic pool, and can drop the 3 kids off at 3 different activities anywhere in Tamworth within a 15 minute timeframe...Life is Easy! The model of critical care has recently changed this year, but for 25 years prior to this the Emergency Physicians had ownership of the ED, ICU and Retrieval Service (with its own helicopter and base). We provide critical care for an area geographically the same size as Tasmania, and the volume of work for the 3 disciplines has recently become unsustainable, necessitating a division into separate services. This has been both positive and negative (and continues to evolve). My interest in EMER came from my 5 years’ service as the Rapid Response Co-ordinator of the ICU in Tamworth, during which time I witnessed a significant number of “near misses” on the wards. I have enjoyed being involved with EMER and am now incorporating it into the local registrar teaching sessions we hold each week, using near-miss cases for educational purposes.

Publications of interest 1.

Ramlakhan S, Qayyum H, Burke D, Brown R. The safety of emergency medicine. Emergency Medicine Journal. 2015.

2. Braithwaite, J. Unlocking the mysteries of the health system. Primary Health Care. 15 Oct, 2015. http:// www.phcris.org.au/news/newsfeed/2015/october/aihi.php?promoid=799&mid=39&stype=twiphc&linkid=119390. promoid=799&mid=39&stype=twiphc&linkid=119390 4

Safety Alerts Our first safety alert is currently being released in time for the ACEM ASM 2015. The safety alerts will be widely distributed through the College website, newsletters, social media and of course through emer.org.au. This first alert was inspired by the EMER case study “Knickers in a twist” published in Emergency Medicine Australasia (available via http://onlinelibrary.wiley.com/doi/10.1111/1742-6723.12473/epdf) .

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Incident of the Month - November The incident below was reported by an ED doctor into www.emer.org.au Clinical presentation - Patient presented with testicular pain. ED consultant assessed - ? torsion testis, but likely morgagni remnant torsion as tender at upper pole. Apyrexial. Hemodynamically stable. 4 hours of pain - therefore time sensitive. What happened? Resident was advised by ED consultant to request surgical registrar to attend and consider surgery to explore if torted. Surgical registrar notified resident that he is busy attending to a duodenal bleed in ICU and therefore would not be attending the patient in a timely fashion. The registrar advised the resident to send the patient to a paediatric hospital where that surgical registrar could see the pt. This would delay definitive assessment and care even further. I intervened as the resident was speaking to the paediatric hospital to arrange a transfer - I called the on call consultant surgeon who promptly attended to the patient in ED and took them to theatre ASAP to assess for torsion. Contributing factors – Surgical registrar busy. Did not understand time frame? Inexperienced resident - following orders. Action taken - ED consultant call to surgical consultant. Factors that reduced the impact – ED consultant intercepting the call. Prevention – Surgical registrars doing their job. ED resident awareness of guidelines regarding torsion. More ED registrars available to assess and discuss with surgical registrar. Consultant to consultant discussion from time zero. Consequence or Outcome - Patient in theatre at 5hrs post onset of pain. Reporter - ED Physician

Contact Us If you have any questions or comments about EMER, please contact us on [email protected] This email is monitored by Australian Patient Safety Foundation staff, who can also be contacted on 08 83022447 www.emer.org.au

EMER: Anonymous Confidential Protected

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