DjHS has a Clinical Risk Management Committee, which reports to the Board. The Committee membership is made up of doctors, nursing and allied health staff. All issues relating to clinical care are reviewed by this Committee. During 2005-2006 several members of the Committee attended training on ‘root cause analysis’. If a health service experiences a major catastrophic event (e.g. operation on wrong patient or body part, medication error leading to death of a patient), this is called a ‘sentinel event’. These events must be reported to the Department of Human Services and a ‘root cause analysis’ is then conducted by the health service to investigate the reasons for this event and put in place steps to prevent further incidents of this kind. We now have staff trained to undertake such an analysis if required; fortunately, DjHS has not yet had a sentinel event.

This Committee also receives reports from various external bodies – for example the local Division of General Practice and the Coroner’s Court - as well as all the internal clinical groups who report to this committee including emergency services, medical officers and nursing staff meetings. Any recommendations for improvements to patient, resident and client care are reviewed by this group. During this past year, the Committee approved the development of some important clinical protocols including transfusion practice, adverse reactions to drugs and vaccines, diabetes management and end of life decisions.