Perioperative Harm: Launch and promoting the case for change
March 2014
Background
The next focus of the Open for better care campaign is on reducing perioperative harm. The
Commission’s Perioperative Harm Programme is ongoing, while the campaign will highlight
perioperative harm key messages from April to end September 2014.
The topic will launch in the week of 14 April. It will be a ‘soft launch’, with a national media
release (likely from the Minister’s office), and launch packs will be sent to quality and risk
managers, DHB CEOs, Chairs and Communications Managers and theatre teams, as well
as other key stakeholders including private providers.
Launch packs will contain:
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covering letter
perioperative harm poster for sector
patient brochure Keeping you safe during surgery
perioperative harm infographic – the case for change.
At the beginning of April we will circulate a media pack to you, with cc to your
communications managers, which will have perioperative harm campaign key messages and
questions and answers. This can be used to develop local media releases.
Regional launches
We encourage you to have DHB/private provider/regional launches of the perioperative harm
campaign topic. As always, it is over to you to choose what approach will work best for your
region/DHB. While the official launch week for the topic is 14 April, anytime in the second
half of April would work well for regional/DHB launches.
Below are some suggestions for a DHB/private sector or regional launch, and for the month
of April when the focus is promoting the case for change.
Launch ideas
Have a perioperative harm-focused
booth, or promotional table in
theatre team rooms.
The Commission can provide:
 a patient safety focused quiz (general focus,
with a couple of perioperative harm
questions – so suitable for all staff). The quiz
can also be run through your intranet.
 A poster about perioperative harm and how
it can be avoided
 The patient brochure Keeping you safe
during surgery
 Open campaign pens and lanyards
 Perioperative harm ‘case for change’
document (includes harm caused, ACC
claims, impact of use of the surgical
checklist). A4 copies and a large laminated
copy available
 A small display for theatre tea rooms that will
include Open branded biscuits, and
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perioperative harm key messages
Please let Falyn Edlin
(Falyn.Edlin@hqsc.govt.nz) know if you would
like to have a perioperative harm-focused booth
or promotional table and we will supply you with
the various collateral.
Release to local media to support
 The Commission will circulate a media pack to
the launch. This could include your
you, with cc to your communications managers,
region’s/DHBs’ perioperative harm
which will have perioperative harm campaign
quality and safety marker process
key messages and questions and answers. This
figures (second quarter figures will
can be used to develop local media releases.
be released in late March).
Articles about launch of
 Commission will draft and supply
perioperative harm campaign focus
for DHB/private provider newsletters Please let Falyn Edlin
(Falyn.Edlin@hqsc.govt.nz) know if you would
like perioperative harm campaign articles
drafted for you.
Throughout April (from launch on 14 April 2014)
Below are some suggestions for promotion throughout April that highlight the case for
change.
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Organise a perioperative harm speaker for grand tounds. The Commission will look
to source an expert for you, if you can make a slot available. Please give us good
advance notice so we can ensure timings work.
Encourage surgical teams to feature on perioperative harm Open posters. Just
provide the photo, names and positions of those in it, and a short quote about why
patient safety is so important to the team, and we will mock up the poster, send it to
you for sign off, and then send you printed copies.
Discuss information/trends from your DHB, as picked up through tools such as
Global Trigger Tools.
Hold a multidisciplinary morbidity and mortality meeting/grand round or other meeting
that focuses on perioperative harm that has occurred in your DHB/hospital or use
external case studies/information.
Hold a debate about what perioperative harm is acceptable/not always preventable
and what types should be considered unacceptable/highly preventable.
Useful information to inform the above will include:
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Internal events/information from:
o your internal reporting systems – there may be some trends that you can
identify in the types of events being reported
o the surgical module of the Global Trigger Tools, if your DHB/hospital is using
this tool to identify errors regardless of harm
o your outcome quality and safety markers from the Commission compared
with other DHBs
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External information could be identified from:
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o
o
o
o
ACC – treatment injury case studies http://www.acc.co.nz/forproviders/clinical-best-practice/case-studies/index.htm
The Commission’s Serious Adverse Events reports
http://www.hqsc.govt.nz/our-programmes/reportable-events/seriousadverse-events-reports/
Health and Disability Commissioner’s decisions and case notes
http://www.hdc.org.nz/decisions--case-notes
Never? a report by the Clinical Human Factors Group (UK), that looks at
nine wrong site surgery cases http://chfg.org/articles-filmsguides/articles/never-a-clinical-human-factors-group-report
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