Safety and quality update: March 2022

10 March 2022

Advisory on HFNO missing circuit tubing; Victorian Duty of Candour amendments; Japanese Encephalitis; New Zealand COVID-19 healthcare quality; Choosing Wisely National Champions Award; Safer Care Vic forum; ACHS QI Lead training.

Safety Alerts

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WebAIRS Advisory Notice for HFNO missing circuit tubing

A recent webAIRS report describes an incident using the HFNO in a spontaneously breathing patient who significantly desaturated during sedation. The attending anaesthetist confirmed a patent airway and unobstructed breathing and then increased the oxygen flow from 20L/min to 60L/min with no effect. The HFNO setup was formally checked, and it was observed that the tubing between the oxygen flow meter and the humidifier was missing. This was corrected quickly, and the oxygen saturation normalised within seconds. The reporter commented that it is easy to miss a failed assembly of the HFNO circuit, if the tubing between the flow meter and the humidifier is not installed correctly.

A more detailed account is available under the menu option ‘Advisory Notices’ for anaesthetists registered with webAIRS after logging in to the members area.

Register with webAIRS

Victorian Duty of Candour amendments passed

After almost five years of consultation with the sector and community, Australian-first Duty of Candour requirements were passed by the Victorian Parliament on 27 February 2022.

From November 2022, public and private hospitals will need to:

  • apologise to any person seriously harmed while receiving care
  • explain what went wrong
  • describe what action will be taken and improvements put in place.

There are also new legal protections around health service apologies and clinical incident reviews that mean they cannot be used in a court of law but will be available to patients or their family members and carers.

Safer Care Victoria are developing guidelines, training and resources to help you prepare and implement the changes at your health service, and to monitor staff compliance.

More information

Japanese Encephalitis declared a Communicable Disease Incident of National Significance in Australia

Australia’s Acting Chief Medical Officer has declared the Japanese encephalitis virus (JEV) situation a Communicable Disease Incident of National Significance. There are now confirmed cases in New South Wales, Queensland and Victoria.

JEV is a nationally notifiable disease in both humans and animals. Clinicians encountering suspected cases should notify both their state or territory department of health and the Australian Government Department of Health immediately.

The Victorian Government has also advised: “Clinicians must consider and test for JEV and other arboviruses in patients with unexplained encephalitis, after other common causes such as Herpes Simplex Virus (HSV), Varicella Zoster Virus (VZV) and enteroviruses have been excluded.” (Source)

More information

Health Quality and Safety Commission New Zealand report on healthcare quality impacts of COVID-19

Aotearoa New Zealand has been recognised internationally for a successful early response to the global pandemic of COVID-19. The report A window on quality 2021: COVID-19 and impacts on our broader health system – Part 1 | He tirohanga kounga 2021: me ngā pānga ki te pūnaha hauora whānui – Wāhanga 1  explores the secondary impacts of the response on selected aspects of the functioning of the health system so we can learn from that experience and shape resilient system responses in the future.

Download the report

Choosing Wisely Australia: National Champions Awards

This year, Choosing Wisely Australia has launched the National Choosing Wisely Champions Awards to recognise Choosing Wisely Champions demonstrating their commitment to promoting the principles of Choosing Wisely in their day-to-day activities. There are four categories for nominations: Health professional, Consumer, Student, or Organisation or team.

A nomination form can be requested from and must be submitted by COB Friday 01 April 2022.

Safer Care Victoria, Quality and Safety Leaders forum, 31 March 2022 (online)

SCV’s Quality and Safety Leaders forum is back. This is a forum for Victorian health service quality and safety leaders, executives, directors and managers from public and private health services to:

  • Share sector quality and safety improvement learnings with peers
  • Network with peers
  • Contribute to driving state-wide improvement
  • Hear about the latest SCV quality improvement work.


Reminder: Australian Council on Healthcare Standards (ACHS) Virtual Quality Improvement Lead Program

The ACHS is running its seventh year of Quality Improvement Lead training, designed ‘to equip you with the knowledge and skills to improve the quality and safety of care for patients/clients.’ The audience of this training includes CEOs, Health Executives, clinicians and Quality Managers.

Registrations close on Wednesday 30 March 2022 and the first virtual session is 7 April.


Last updated 16:32 12.07.2022