• Medical Orientation

Policies, Protocols and Guidelines

As an employee of Bendigo Health you are contractually obliged to adhere to Bendigo Health policies and protocols.  Many of these pertain to clinical care and are designed to provide best practice standards and reduce variability of care.  Most contain some element that is specific to Bendigo Health (we are unique).

Policy: defines an organisation’s official position in relation to any issue pertaining to its business or services. It is a statement of intent, based on reasonable assumptions, which must be followed when making decisions.

Protocol: a sequential set of approved instructions which must be followed, relating to a process and or completing an activity aimed at standardising practise and minimising variation. It will contain policy points early in the document that must be considered before commencing the instructions

Guidelines: statements/advice to assist staff to make decisions and take actions where it is not possible or beneficial to mandate a particular path. They may identify an alternate treatment or require staff to apply their expertise. Unlike policy and protocols, guidelines are not prescriptive documents.  Many peak bodies produce guidelines and there is an ongoing process to standardise these where national or state guidelines exist (SaferCare Victoria / Royal Children’s Hospital).


PROMPT is the online repository for approved documents at Bendigo Health.  Policies, protocols, guidelines, BH patient information leaflets, emergency plans, committee terms of references, employee and payroll forms, etc. are all searchable on PROMPT via the intranet.

The PROMPT page on Bendigo Health intranet also has information about how to view PPGs from external organisations should you wish to research how other organisations do things (e.g. Police Bloods at Cabrini Health, Stroke calls at Box Hill Hospital, Medicinal Cannabis at Peninsula Health).

All Bendigo Health documents are vetted through an extensive peer and committee review process before approval for publication on PROMPT and are updated on a regular basis to reflect changing practice (there is a protocol for this too).

If you notice an issue with, error in or omission from a PROMPT document relating to ED care please email Richard Smith rdsmith@bendigohealth.org.au with the details.

Top 10 PROMPT Documents to know in ED:

  • Loddon Mallee Region Inter-hospital Transfers Protocol
    • Explains who has the responsibility to accept incoming patient transfers and how this is arranged.
  • Emergency Department Admissions to Inpatient Units Protocol
    • Explains the admission process from ED to different specialties.
  • Unplanned Patient Representation Management in the Emergency Department Policy
    • Representations within 72h of ED discharge are to be seen by a different doctor and reviewed by a consultant (or registrar overnight).
  • Emergency Department Patient Discharge Protocol
    • Lists the criteria for safe discharge.
  • Clinical Incident Management Protocol
    • Explains the actions to take when an incident occurs.
  • Make A Call “MAC” Emergency Department Protocol
    • Explains how the deteriorating patient in the ED is recognised, escalated to senior doctor and reviewed.
  • Management of Critical Bleeding (Massive Transfusion) Protocol
    • Explains the exact process of getting blood products to the bedside in a hurry, how to order it, what terminology to use, and what exactly the blood bank will send you. It is better to know this information in advance.
  • Emergency Department care and referral of Pregnant women >20 weeks gestation Protocol
    • Ensures that Women’s Health are notified by ED of any presentations to ED of women >20 weeks and defines which team has responsibility for certain presentations.
  • Blunt Chest Wall Trauma Protocol
    • Identifies patients at risk of deterioration after chest wall injury and how to prevent this.
  • Eating Disorders Acute Medical Presentation (Adult) Protocol
    • Defines clear history and physiological parameters for admission under either psychiatry or medicine.


Bendigo ED’s approach to adverse patient safety events

Occasionally, inevitably, things go wrong.  We all want this to be less occasional and less inevitable.

Emergency Medicine is a high risk specialty for adverse patient safety events mainly due to the need to make rapid treatment decisions with limited information, the lack of day-to-day control over demand and overcrowding, and the competing priority of efficiency over comprehensive patient-centred care.  Added to this are a multitude of other system and human factors that can influence the care a patient experiences for any given episode.

But don’t forget we also have a lot going in our favour.  We have good levels of immediately-available consultant support and supervision.  We have a highly successful training programme.  We have experienced nurses who speak up when they have patient safety concerns.  We have staff with long experience at Bendigo ED and long institutional memories.  We have a strong patient safety culture.

When managing patient safety, our first goal is prevention - by providing a system in which adverse events are less likely, serious adverse events less likely still, and compound or recurrent adverse events extremely rare.

Our second goal is recognition - by providing a system in which staff feel safe to report adverse events and feel confident that the outcome of adverse event reporting is geared towards system improvement.

Our third goal is mitigation - by providing a system in which when errors occur they are lower in consequence because they are identified quickly, managed early and managed well.

Notice that these goals are all system-and-process-oriented.  Our patient safety culture approach focuses on systems and processes and not on assigning individual blame.  If you are personally affected by an adverse event we want to support and work through it with you.

What to do if there is an error, adverse outcome, or unhappy customer?

Firstly, if you find yourself in a hole, stop digging and reassess.

Secondly, if an issue can be resolved at the time, do so.  The earlier the better.

Thirdly, don’t do nothing.  Escalate it to a senior staff member at the earliest opportunity - things always gets back to us eventually anyway.

Senior staff can refer to the Clinical Incident Management Protocol (on PROMPT) for the steps to take in the acute phase after an incident occurs.  If a sentinel event has occurred please notify the ED director at the earliest opportunity during waking hours.  Putting in a VHIMS report will suffice as a notification for all other incidents.  If you are not sure about whether to report an incident please ask/email either Richard, Simon, or Yvonne.

All complaints and incidents are collated and reviewed by the consultant with the Quality and Safety portfolio, currently Richard Smith.  It is our practice to notify any key ED doctors involved of the case and the details of the incident or complaint, either by an email to your Bendigo Health email address, a corridor discussion, or via your DEMT, HMO supervisor, or Intern supervisor.  You will be forwarded this notification regardless of the severity of the incident or the veracity of the complaint.  Most times it is just FYI, no action needed.  Most doctors want to know if they have been involved in any negative outcomes but if you prefer not to hear about any negative patient feedback please let Richard know.

If you have been involved in a serious adverse patient safety event it is a good idea to:

  • Make detailed personal notes for yourself while your memory is fresh:
    • what occurred from your perspective and the context of the decisions that were made.
    • Names of any supporting witnesses.
    • take a snapshot of the department at the time. How busy was it, was it short-staffed, was there access block, were there other competing priorities at the time, etc.
    • what was going on in your life outside work at the time, personal stressors, tiredness, illness, etc.
  • Discuss with either Simon, Richard, or Yvonne. We know how to help you.
  • Consider discussing with your medical indemnity provider.
  • Remember to look after yourself and your wellness in the aftermath.

Open Disclosure and Duty of Candour

Open disclosure is amazingly effective at defusing incidents, satisfying patients, and preventing future complaints and litigation.  It is a powerful tool and should be done as early as possible, ideally by the consultant in charge at the time the incident is identified.

From 30 Nov 2022, Victorian hospitals have a Statutory Duty of Candour when responding to a Serious Adverse Patient Safety Event (SAPSE).  Stage 1 of this process is to Apologise and provide initial information:

  • The health service entity must provide a genuine apology for the harm suffered by the patient and initial information, as early as practicable (and no longer than 24 hours) after the SAPSE has been identified by the health service entity.
  • The apology must be provided to the patient, or if the patient lacks capacity or has died, the patient’s immediate family, carer, NOK or a person nominated by the patient, as early as practicable and clinically appropriate with regards to the needs of the patient. The health service entity may decide on the appropriate person to provide the apology, such as a suitably qualified health professional.
  • The health service entity should consider the following in providing the apology:
    • express compassion, regret or sympathy
    • say the words ‘I am/We are sorry’ and
    • avoid jargon or legalistic wording.
  • An apology is not an admission of liability. In a civil proceeding where the death or injury of a person is in issue or is relevant to an issue, an apology: (a) does not constitute an express or implied admission of liability for the death or injury; and (b) is not relevant to the determination of fault or liability in connection with that proceeding.  This is relevant whether the apology is made orally or in writing or is made before or after the civil proceeding was in contemplation or commenced.  Evidence of an apology made by or on behalf of a person or a health service entity in connection with any matter alleged to have been caused by the person or health service entity is not admissible in any civil or disciplinary proceedings as evidence of the fault or liability of the person or health service entity in connection with that matter.
Provide initial information:
  • The initial information may be provided with the initial apology, however, should ideally be performed by a suitably qualified health professional.
  • When providing initial information, the health service entity must:
    • provide factual information that is known at the time about the event;
    • offer written patient information on the adverse event review process (e.g. information flyer); and
    • provide the details of key contacts the patient can liaise with, including where relevant, an Aboriginal Hospital Liaison Officer (AHLO).
  • When providing initial information, the health service entity should:
    • be sensitive and empathetic;
    • acknowledge that these events can be confronting matters for patients to deal with; and
    • avoid inferring blame, admitting fault or offering opinion.
  • The health service entity may also consider providing further information including:
    • confirming the patient knows how to access their health records if necessary;
    • confirming any specific needs of the patient, including cultural or linguistic requirements;
    • confirming how the patient would like to be communicated with;
    • attempting to answer any questions the patient has since providing the initial information. If the questions cannot be answered immediately, the health service entity should record these questions and inform the patient they will be addressed as part of the SDC process; and
    • outlining how the patient can raise concerns outside of the SDC process, including the health service entity’s internal complaints process, or the Health Complaints Commissioner (HCC) or Mental Health Complaints Commissioner (MHCC).
  • Where the harm has resulted in the patient’s death, the health service entity should consider:
    • advising the NOK that there may be additional processes involving third parties, such as the Coroner, and that coronial investigations or inquests may incur lengthy timelines; and
    • providing psychological support for the NOK and any staff affected by the death.


Reporting of incidents and feedback is encouraged at Bendigo ED because it is one of the main ways we can identify and address any issues with the quality and safety of our service.  Bendigo Health uses the Victorian Health Incident Management System (VHIMS) for incident and patient feedback reporting and management.  Our goal is to learn from adverse events and identify any system improvements that can be made to prevent similar events in the future.

Incident reports in VHIMS vary from reports about clinical errors to patient harm, organisational issues and OH&S incidents.  Not all incidents require a VHIMS and most communication issues can and should be resolved at the time they occur.  VHIMS is not the place to report or further your interpersonal conflicts.

Junior medical staff should discuss all incidents with a consultant before posting a VHIMS report.  If the incident involves a consultant, discuss directly with the ED director or your mentor.  (The consultant should know to self-report anyway).

When reporting incidents in VHIMS, please refrain from using emotive language and blame.  Be professional and stick to the facts.  Avoid using staff names where this is not relevant.

To log a VHIMS incident requires having a login to VHIMS.  You can apply for this by emailing the Quality department, however they will usually tell junior staff that they don’t have enough licences for new logins.  Most of the ED consultants, ANUMs and senior registrars have VHIMS access, so ask them.

Morbidity & Mortality Review (M&M)

Each month a selection of clinical incidents and patient feedback is chosen for case review at the M&M meeting.  Some cases are mandatory for us to review at M&M and the rest are selected to promote discussion, learning, and resolution of any internal ED confusion, controversy or misconceptions.

M&M is usually presented by an ED registrar.  Any ED staff member is welcome to attend and we frequently invite other specialties.  At the meeting, no individuals will be identified.  You are free to attend or not, speak up or not.  After discussion of the incident in context we then discuss any potential systems changes to decrease the chances of recurrence.  We believe that in a well-run and supportive M&M there is no benefit to be achieved by focusing on individual actions or blame so the senior staff will steer the discussion away from that.  We want to provide a safe environment for objective case review.

The content of the presentation, discussion and minutes of the meeting are confidential and not to be shared outside of the distribution list.  All material presented and discussed is protected under section 139 of the Health Services Act.

We do attempt to give advance notification to key ED staff involved in an M&M case.  It is valuable when staff who were with the patient at the time can contribute to the discussion.  Please check the agenda, emailed a few days before the meeting, in case we have missed you.  Ideally we will have already asked you for your perspective whilst preparing the review.

Learning from Success:

System improvement and learning does not only have to come from studying error or negative incidents.  Reflecting on the positive aspects of our work, cases that went well, positive feedback and achievements can help us identify practices and positive capacities to encourage.

Please email Richard Smith rdsmith@bendigohealth.org.au with details (including UR number) of the following:

  • Successes that had the potential to go poorly (or have in the past) but didn’t.
  • Successes that needed explaining.
  • Near-misses (good or lucky?)
  • Cases where the whole team just nailed it.
  • Novel work adaptations/variations.
  • Anywhere Work-as-Done differs from Work-As-Per-Policy.


Simple ways to practice safely – the Bendigo way:

  • Listen to the nurses and act on their concerns.
  • Always introduce yourself and explain your role to the patient and everyone with the patient. We all look the same and it is not often clear who is who.
  • Check the alerts and allergies for every patient, every time. If there is an alert or allergy that is not recorded but should be, enter it into EPR yourself.
  • Document well. Concise and complete documentation must occur at the time of care or as soon as practicable by the clinician providing the care.
  • Address all of your patient’s concerns. Especially the elephant in the room.
  • If a patient has been waiting several hours to be seen, try to prioritise a brief rapid clinical assessment to initiate and direct their care.
  • Discharge safely.
  • Provide fact sheets / patient information pamphlets wherever possible. (There are multiple links to these on EDCentral under Clinical Resources)
  • Clinical handover – be cautious and comprehensive, it is a high risk time.
  • Ensure you have handed over or discharged all of your patients off the EPR at the end of the shift.
  • SSOU – no patient should leave SSOU without their pathology & radiology results checked or their discharge summary completed.
  • If discharging a patient to a care facility, contact that facility to let them know and provide a copy of the discharge summary to go with the patient – BH discharge summaries are only sent to the patient’s GP which can leave the care facilities out of the loop.
  • Follow up the results of tests you have ordered. Sign off your radiology reports.
  • Referrals – use ISBAR format.
  • Escalate/ask when unsure.
  • Know your legal responsibilities (e.g. Mental Health Act, Police Bloods, Child protection, duty of care, etc.) and escalate when unsure.
  • Practice graded assertiveness if you see anything going wrong.
  • Pick up and put away anything left out that could be used as a weapon.
  • Clean up after yourself and put things back in their proper place e.g. procedure trolleys, ultrasound machines, ENT headlight, tonopen, etc.
  • Try not to rush the medical clearance of mental health patients.
  • Could this be sepsis?
  • For every shift try to meet your own personal standards for the way you act, how you communicate, and how you work.

How can I get involved in quality and safety at Bendigo ED?

Nurses contact Rebecca Fawcett rfawcett@bendigohealth.org.au

Doctors contact Richard Smith rdsmith@bendigohealth.org.au


ED Management Plans

Around 80-100 patients have ED management plans at Bendigo health.  They are a mixture of frequent-flyers with combined psychological/medical needs and other patients with very specific specialist care needs.  The main purposes of ED management plans are:

  • To assist staff to meet the specific needs of the patient
  • To direct actions when the meeting of these needs requires care that varies from usual practice
  • To avoid over-investigating and over-treating
  • To promote consistency of care between providers over time
  • To facilitate early contact with relevant healthcare providers
  • To prevent violence and harm

Unless the presenting problems are different from the plan or there are safety concerns, please always try to manage these patients consistently with their plan.  Consistency is the key - we have been treating many of these patients for years and it is possible for an entire care plan to be derailed by a single ED presentation managed “off-plan”.

If you notice that a patient is presenting often with a variety of problems or representing multiple times with the same problem despite adequate referrals and investigations being done, please email the ED consultant in charge of the Management Plan portfolio.  You can also make a direct referral to HARP if the patient meets their referral criteria.


Opioid Stewardship in the ED:

  • Avoid opioids when possible with the use of non-opioid analgesics (WHO analgesic ladder) and other adjunct therapies (splints/ice/etc.)
  • If opioids are indicated, prescribe the lowest dose for the shortest duration you can.  Maximum supply 3 days (adjust for pt’s ability to access GP).
  • Immediate-release preparations are safer.
  • Check SafeScript Victoria before prescribing.
  • Educate your patient.
  • Remember to co-prescribe a stimulant laxative (Coloxyl + Senna).
  • Risk factors for opioid harm:
    • older people, infants and children, pregnant and breastfeeding patients, patients with a disability
    • patients with unstable adverse social circumstances, patients with psychological comorbidities, and patients with substance use disorders
    • patients already on opioids, or other CNS depressant medications (benzodiazepines, gabapentinoids)
    • COPD, OSA, DM, HTN, hepatic or renal impairment, obesity, neurological disease.

Ref: Opioid Analgesic Stewardship in Acute Pain Clinical Care Standard 2022