Annual Report 2011/2012 Royal Darwin Hospital Board
Tabled paper 432
Tabled Papers for 12th Assembly 2012 - 2016; Tabled Papers; ParliamentNT
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the Northern Territory Audit of Surgical Mortality is an initiative of the Royal Australasian College of Surgeons and its Fellowship; it aims to peer review clinical management of cases where deaths occurred during surgical admission in the Northern Territory; funding is provided by the Northern Territory Department of Health; and the Audit began in June 2010. Aims to improve the quality of healthcare through feedback and education; to feed back in individual and group formats; to produce de-identified, quantitative reports, to further improve and reform health provision in Northern Territory; and to encourage clinical professionals to engage in quality and safety initiatives in order to bring about improvements in care. Criteria of the Australia and New Zealand Audit of Surgical Mortality it is independent; it is external; it is peer-review; it is systematic; it is routine; it is objective; and it is confidential (all audits are covered by qualified privilege at a commonwealth level). Clinical Incidents nearly all issues can be considered systems failures, and as such, organisational factors are responsible; there were 5 areas of concern/adverse events in 3 patients (9% of audited patients); reasons Identified: o delay in transfer to surgical unit; o poor communication between physician and surgeon; o technical issue with a drain / catheter; o delayed diagnosis; and o only one was a specific surgical technical problem. Departmental Support and Assistance o Hospital Medical Records Departments; Royal Darwin Hospital Board 2011/2012 Annual Report Page 18 of 29
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