The Office of the Health Ombudsman received mandatory notifications in relation to a number of registered practitioners who, it was alleged, had placed patients at risk of harm because they had not completed TVOs as required.

Wider learnings and recommendations for service improvements

The investigation identified opportunities for improvement and proposed recommendations relating to:

• Amendment to the procedure for TVOs to specifically prohibit retrospective signing for TVOs not undertaken.
• Progression of the plan to move to electronic recording of TVOs.
• Nurse Unit Manager to continue TVO practice auditing consistent with Tier 1 and Tier 2 monitoring required by Therapeutic Visual Observations for Mental Health and Other Drugs Services, Queensland Health Guideline, until electronic recording can be introduced.
• Upon implementation of electronic recording of TVOs, strengthen the Tier 3 clinical audit tool with reporting to patient safety committee.

Read the snapshot report (PDF 131KB)