Safer Care - Our quality, your safety

Hospitals can be unfamiliar places and patients may be weak, dizzy, or less steady than they expect. A fall in the hospital or a residence can delay a patient’s recovery. In older people, it can contribute to a loss of independence. A serious fall can cause a brain injury or require surgery for a badly broken bone. While uncommon, in some cases it can lead to a patient’s death, especially in older people. Staff are encouraged to report all falls (an event that results in a person coming to rest inadvertently on the ground or floor or other lower level, including near-miss falls and minor trips or slips) that occur while receiving care by Alpine Health.

What does this mean?

In the most recent period, a rate of 0.73% means that for every 137 days patients stayed in acute hospital beds at Alpine Health, one patient experienced a fall.  In the residential setting, a rate of 0.32% means that for every 315 days residents stayed in residential care at Alpine Health, one resident experienced a fall. This includes near-miss falls and minor trips or slips.

What are we doing?

Alpine Health uses a range of strategies and tools to reduce the risk of falls and harms caused by falls.  Risk reduction strategies include;

• Encouraging the use of mobility aids and non-slip socks
• A comprehensive approach to falls risk assessments
• Dietician review
• Medication reviews
• Patient-centred strengthening programs with Allied Health
• Improving the living environment for residents with cognitive impairment

Falls harm reduction strategies in place include;

• Strengthening programs designed by physiotherapists aim to make residents stronger, not only reducing an individual’s frailty when they fall but reducing the likelihood of falling by being stronger and lowering beds
• De-cluttering living environments
• Ensuring adequate lighting
• Ensuring call bell availability

• Falls management training for staff (e.g. appropriate lifting after a fall to reduce the likelihood of further injury).

All falls are reported into Alpine Health’s risk management system, reviewed by nurse unit managers and in-depth incident reviews are carried out if the outcome of the fall is more severe.

Alpine Health also aligns current falls management practices against the Comprehensive Care Standard under the National Quality and Safety Health Care Standards.

What can you do?

Patients, families, and carers have an important role to play in preventing and managing falls in hospitals.  For more information please download the Information Sheet on Preventing Falls in Hospital. Or watch the following video about how to prevent falls (as developed and shared by Yarram and District Health Service in partnership with consumers and the Health Issues Centre). 

Video: Preventing Falls

Medicines are the most common healthcare treatment. Used correctly, they are an effective and important part of care. However, medication errors can cause harm and, in rare cases, death. We report and investigate these cases to help prevent future errors.

What does this mean?

In the most recent period, a rate of 0.92% means that for every 109 days patients stayed in acute hospital beds at Alpine Health, one patient experienced a medication error.  In the residential setting, a rate of 0.09% means that for every 1102 days residents stayed in residential care at Alpine Health, one resident experienced a medication error.

What we are doing?

Alpine Health has established a Drugs and Pharmaceutical committee to increase the governance of medication practice.  As part of the requirements for the Medication Safety Standard under the National Quality and Safety Health Care Standards, we are continuously reviewing the adequacy of staff education, risk assessments and patient/resident review regarding medication management.

Hospitals use a range of approaches to prevent and treat pressure injuries (sometimes called bed sores or pressure ulcers). Anyone who needs to be in a bed or chair for a long time is at risk of developing a pressure injury. They are most common on bony parts of the body like the hip, tail bone, or heel.

What does this mean?

In the residential setting, a rate of 0.05% means that for every 2203 days residents stayed in residential care at Alpine Health, one resident experienced a pressure injury. 

What are we doing?

Alpine Health conducts pressure injury risk assessments on admission and throughout a patient/resident’s stay. Staff undergo training and implement strategies to ensure that the risk of pressure injuries are reduced (e.g. appropriate mattresses being used, encouraging movement, hydration and nutrition reviews). If a pressure injury is identified, appropriate wound management is applied and strategies are put in place to reduce the chance of the wound worsening.

Alpine Health is also aligning current pressure injury management against the requirements of the  Comprehensive Care Standard under the National Quality and Safety Health Care Standards.

What can you do?

Patients, families, and carers have an important role to play in preventing and managing pressure injuries. For more information please download the following Information Sheet on Skin Care & Preventing Pressure Sores. Or watch the following video about how to prevent pressure injuries (as developed and shared by Yarram and District Health Service in partnership with consumers and the Health Issues Centre). 

Video: Preventing Pressure Injuries

All public hospitals and residential care services in Victoria are required to participate in active surveillance for certain infections.  They are what most people know as “Super Bugs” and can have very significant impacts on the health of patients. They are generally resistant to some classes of antibiotics so they are harder to treat. They can cause wound, chest or bloodstream (blood poisoning) infections. These resistant infections include, “Golden Staph” whose medical name is Methicillin Resistant Staphylococcus aureus (MRSA) and Vancomycin Resistant Enterococci (VRE). Another infection we monitor closely is called Clostridium difficile or C.diff.  This infection is usually caused by the patient having been on antibiotics, and can result in severe and debilitating diarrhoea, and sometimes death.

Healthcare associated infections have several definitions and may be associated with healthcare exposure that does not include an admission to Alpine Health, i.e., they may have been in another hospital recently also. These infections will be marked with an *.  All residential care infections are considered healthcare related. Sometimes people develop infections when they are at home, these are classed as “community associated infection”.

Overall, Alpine Health sees very low numbers of reportable infections.

What does this mean?

In the most recent period, 1 infection was reported in Alpine Health facilities. 

What are we doing?

Alpine Health uses a range of approaches to decrease the chances of hospital-acquired infections:

• Ongoing training staff in aseptic technique.
• Hand hygiene auditing and feedback.
• Ongoing training in staff hand hygiene techniques.
• Regular routine cleaning.
• Enhanced cleaning in outbreaks and with infectious conditions.
• Bare below the elbow campaigns – hand hygiene cannot be carried out correctly if the staff member is wearing wrist and hand jewellery (a plain wedding ring is allowed).
• Infections are reported to government bodies and to the board of directors.

What can you do?

• Practice good respiratory hygiene, cover your mouth when you cough, put used tissues in the bin and wash hands after blowing your nose.
• Do not visit patients or residents if you are unwell yourself.
• Wash your hands at the hand hygiene stations at all the entrances upon entering and leaving the building.
• As a family member or visitor feel free to ask staff to remove watches/jewelry and wash their hands before attending to your loved ones’ care.