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Safer Care - Our quality, your safety

Providing healthcare is complex and high risk. This relates to the unpredictability of human illness and multiple skills required of the health care team to provide safe care. Despite, these complexities, quality and safe care is paramount at Alpine Health. Clinical governance are the systems established by Alpine Health that have a shared responsibility with the common goal of optimizing your care so it is safe, effective, high quality and continuously improving. Clinical governance continues to be strengthened by our;

  • organisational committee structure
  • improving quality systems
  • analysis of clinical indicators
  • encouraging a culture of transparent incident reporting
  • encouraging consumer input into service planning
  • Accreditation against National Quality and Safety Standards.

Our performance in key clinical areas

One way that Alpine Health measures and analyses safety and quality performance is through analysis of incidents statistics and patient data.  Analysis of incidents reports by staff help to identify trends in clinical performance and highlight areas for more comprehensive investigation or changes to our systems.

Alpine Health submits this data to the Victorian Department of Health and Human Services and we share this information with other similar sized organisations to benchmark our performance.

This ‘Our Quality, Your Safety’ section of the website aims to provide patients, families, residents and the wider community with a view of clinical key performance areas in perspective to our patient/resident load.

Quality & Safety Areas 

See our monthly clinical indicator dashboard to gain a monthly perspective of Alpine Health’s performance against a quality and safety indicatorsEach dashboard is prepared at the end of each month, prepared for internal review (as per Alpine Health's clinical governance structure) before public review (dashboards are two months in arrears).

 

Falls at Alpine Health

Hospitals can be unfamiliar places and patients may be weak, dizzy, or less steady than they expect. A fall in hospital or in 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 which 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.

FallsTime Period: Jan 2019 No.of Falls Bed days Rate (%)
Acute (Hospital) 3 642 0.46%
Residential 33 2298 1.43%
 
What does this mean?

In the most recent period, a rate of 0.46% means that for every 214 days patients stayed in acute hospital beds at Alpine Health, one patient experienced a fall.  In the residential setting, a rate of 1.43% means that for every 70 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
  • 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 aiming to make residents stronger, not only reducing an individual’s frailty when they fall but reducing the likelihood of falling by being stronger and lowered 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 is also aligning current falls management practise against the Comprehensive Care Standard under the National Quality and Safety Health Care Standards.

What can you do?

Patient, families, and carers have an important role to play in preventing and managing falls in hospital.  For more information please download the Information Sheet on Preventing Falls in Hospital.

 

Medication errors

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.

Medication Errors
Time Period: Jan 2019
No. of medication incidents reported  Bed days Rate (%)
Acute (Hospital) 4 642 0.62%
Residential 9 2298 0.39%

What does this mean?

In the most recent period, a rate of 0.62% means that for every 161 days patients stayed in acute hospital beds at Alpine Health, one patient experienced a medication error.  In the residential setting, a rate of 0.32% means that for every 255 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 practise.  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.

 

Pressure Injuries acquired at Alpine Health

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 of pressure injury. They are most common on bony parts of the body like the hip, tail bone, or heel.

Pressure Injuries
Time Period: Jan 2019
No. of pressure injuries reported  Bed days Rate (%)
Acute (Hospital) 0 642 0%
Residential 2 2298 0.09%
 
What does this mean?

In the most recent period, a rate of 0.09% means that for every 1149 days residents stayed in bed at an Alpine Health residential care facility, one patient/resident developed 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.

 

What happens when things don’t go to plan?

Providing health care and services is complex and sometimes the treatment received or outcome isn’t always in line with the expectations of patients/resident/clients or even the clinicians providing the care.

If something doesn’t go to plan, Alpine Health has systems and processes in place to ensure that these circumstances can be fed back to Alpine Health and investigated to reduce the likelihood of the adversity happening again.   

Some of the processes that Alpine Health has in place when things don’t go to plan include;

If you feel that the treatment that you or someone you care for hasn’t gone to plan or wasn’t adequate, you can provide feedback via Alpine Health Feedback forms or contact the Health Services Manager.

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