Quality Improvement

Reducing harm

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Reducing blood collection errors in our emergency departments

Reducing blood collection errors in our emergency departments

What is a blood collection error?

Blood collection errors fall into two groups:

  1. Accuracy of information:  errors made in the patient identification process and/or documentation process.
  2. Specimen integrity:  errors made in the process of drawing the blood and transferring into tubes for processing.

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Delirium prevention & management

Delirium prevention & management

What is Delirium?

Delirium is sudden confusion which develops over hours to days.  It is different from dementia, such as Alzheimer's disease, which is a chronic confusional state that develops and progresses over time.

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Pressure injury prevention

Pressure injury prevention

What is a pressure (ulcer) injury?

A pressure injury is an injury to the skin and/or the tissues under the skinConstant pressure on an area of skin reduces blood supply to the area.  Over time, it can cause the skin to break down and form an open sore (ulcer).  Pressure injuries are more likely to form if a person is in hospital and is confined to a chair or bed.

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Venous thromboembolism (VTE) prevention

Venous thromboembolism (VTE) prevention

What is Venous Thromboembolism (VTE)?

Venous thromboembolism (VTE) is a condition that includes both deep vein thrombosis (DVT) and pulmonary embolism (PE)DVT is the formation of a blood clot in a deep vein - usually in the leg or pelvic veins.  The most serious complication of a DVT is that the clot can dislodge and travel to the lungs, becoming a life-threatening pulmonary embolism.


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Falls prevention programme

Falls prevention programme

What is a fall?

A fall is defined as “inadvertently coming to rest on the ground, floor or other lower level”.

The "banana man" is a symbol used on patient folders to indicate a patient has had a previous fall, and a magnet is used on the ward whiteboard to indicate an inpatient fall.


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Hand hygiene NZ

Hand hygiene NZ

What is Hand Hygiene New Zealand?

Hand Hygiene New Zealand (HHNZ) is a national quality improvement initiative led by Health Quality and Safety Commission (HQSC), aiming to improve hand hygiene practice in New Zealand hospitals. This initiative commenced in early 2012 with quarterly ‘Gold Audits’ performed by trained auditors.  The audit measures how many times staff comply with the World Health Organisation’s 5 moments of hand hygiene.

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Target zero central line associated bacteraemias (CLAB)

Target zero central line associated bacteraemias (CLAB)

What is a central line associated bacteraemia (CLAB)?

A central line associated bacteraemia (CLAB) is an infection of the blood (bacteraemia) associated with a central line.  Central lines are catheters that are inserted in a large vein near the heart and are used to give medications or fluids.  They are frequently used in Intensive Care Units (ICUs).


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Surgical site infections: understanding the problem

Surgical site infections: understanding the problem

What is a surgical site infection?

A surgical site infection (SSI) is an infection that occurs after surgery in the part of the body where the surgery took place

SSIs can be categorised according to the layers of tissue the infection infiltrates.  In some cases the infection may be superficial involving the skin only, while in other cases they can be more serious and can involve tissues under the skin, organs, or implanted material (such as an artificial joint).


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Reducing catheter associated urinary tract infections (CAUTI)

Reducing catheter associated urinary tract infections (CAUTI)

What is a Catheter Associated Urinary Tract Infection (CAUTI)?

A urinary tract infection (UTI) is an infection involving any part of the urinary system, including the kidneys, urethra, bladder and ureters.  UTIs are the most common type of healthcare associated infection.

Approximately 75% of UTIs acquired in hospital are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine.  Between 15-25% of hospitalised patients receive urinary catheters during their hospital stay.  The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter.  Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.


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Falls prevention II: zero falls with harm

Falls prevention II: zero falls with harm

What constitutes harm from a fall?

Falls frequently result in harm.  This can include:

  • death
  • a knock to the head causing concussion or a brain injury
  • a fracture
  • a dislocation of any joint
  • a cut requiring stitches
  • teeth or dentures chipped requiring repair or replacement

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