Patient-related incident data

Incident Management Process

NSW Health is committed to learning from incidents. When an incident occurs, the health service must undertake a series of steps to understand and address system issues. The steps are displayed below.

Figure 2.

Information Management Process

Severity of patient-related incidents

Patient-related incidents notified in ims+ and Riskman are allocated a Harm Score. This directs the level of review and action required for an adverse event. The Harm Score is based on the severity of the outcome for the patient and any additional care or treatment requires following the incident and is automatically calculated by ims+ based upon selections made by staff.

The Harm Score is confirmed by a manager as soon as possible following the incident notification. The most serious incidents are rated as a Harm Score 1. The other possible scores in declining order of severity are Harm Score 2, Harm Score 3 and Harm Score 4.

During the July to December 2021 reporting period, a total of 83,355 patient-related incident notifications were reported by NSW public hospitals and St Vincent’s Health Network. This represents a decrease (7 per cent) in the overall number of incident notifications when compared to the previous reporting period.

The majority of incidents reported in July to December 2021 (97% per cent) were rated as a Harm Score 3 or Harm Score 4 which resulted in minor or no harm to the patient.

Serious patient-related incidents in health care are extremely rare, with 2 per cent of incidents notified rated as Harm Score 1 or Harm Score 2.

Incidents without a confirmed Harm Score are generally indicative of an investigative timeframe delay, from the initial notification of an incident to the review and confirmation by a manager. At the time of publication, blank Harm Scores accounted for approximately 1 per cent of all reported patient-related incidents.

Figure 3.

Patient-related Incidents by Severity

*All data obtained from ims+ and Riskman. Excludes data relating to private hospitals.

Measuring patient-related incidents

Reporting the number of patient-related incidents in relation to hospital activity provides greater insight and context than reporting on the actual number of incidents alone. NSW Health uses the measure of incidents recorded per 1,000 acute care bed days to provide this context. This measure allows NSW Health to compare the rate of incidents by their severity over time, according to activity. The rate does not account for patient complexity. Acute care bed days are defined here.

During the July to December 2021 reporting period, the patient-related incident rate was 24.17 per 1,000 acute care bed days. This represents a slight decrease when compared with the preceding 6 month reporting period January – June 2021 (24.67 per 1,000 acute care bed days).

Figure 4.

Figure 4 Patient-related notifications by severity

*All data obtained from ims+ and Riskman. Excludes data relating to private hospitals.

Principal Incident Types

When a patient-related incident is notified, staff select one of the 25 Principal Incident Types (PITs) in ims+. The PIT is entered by notifiers at the time of incident notification and assists the notifier to describe the incident in further detail.

During the review process, managers confirm the PIT selected. A number of PITs are split further into sub-categories which are referred to as Level 2 and Level 3 PITs. This allows certain types of incidents to be further categorised. The top five PITs by volume for this reporting period are displayed below.

Figure 5.

Principal Incident Types

*Data includes patient related incidents (all Harm Scores) recorded within ims+ during the reporting period. Excludes data relating to private hospitals and St Vincent's Health Network.

The top 5 PITs align with those identified in the previous reporting period for January – June 2021.

Skin Integrity

The Skin Integrity PIT contained within ims+ enables the notification of skin specific issues including pressure injuries, skin tears, bruises, moisture associated skin damage, lacerations and burns.

Many factors can influence skin integrity, including a person’s age, mobility, body weight and external factors such as pressure or moisture.

During the July – December 2021 reporting period, the majority (98 per cent) of reported Skin Integrity related incidents were assigned either a Harm Score 3 or Harm Score 4, which resulted in minor or no harm to the patient. Skin Integrity related incidents mainly related to:

  • Pressure injuries (68 per cent)
  • Skin tears (21 per cent)

Pressure injuries (also referred to as pressure ulcers or bed sores), are injuries to the skin caused by unrelieved pressure and may occur when patients are unable to move due to illness, injury or surgery. Pressure injuries can happen from lying or sitting in the same position for too long. They can be painful and may take a long time to heal.

Skin tears are injuries to the skin that can be caused by falling or bumping into furniture. Skin tears occur mainly in the elderly as skin can be more fragile and prone to damage more easily. Some medications, such as steroids can make the skin thinner.

Further information relating to pressure injuries and their prevention can be found on the CEC website.

Concerning Behaviour

Incidents that relate to a patient’s behaviour are classified using the Concerning Behaviour PIT. This PIT includes the areas of aggression (physical and/or verbal), self-harm, risk taking and patients absconding from care.

Across the July – December 2021 reporting period, 98 per cent of concerning behaviour incidents were assigned as either a Harm Score 3 or Harm Score 4. Verbal and/or physical aggression of patients accounted for over half of these incident notifications. A breakdown by aggression specific Level 2 PIT categories is provided below:

  • Aggression – both physical and verbal (28 per cent)
  • Aggression – physical (18 per cent)
  • Aggression – verbal (12 per cent).

Falls

Patient falls in hospital can be a major cause of harm and may result in increased hospital length of stay. Hospitalised patients older than 65 years of age have a significantly higher risk of falling.

The prevention of falls is a significant health issue, and minimising harm by focusing on key factors such as frailty, cognitive impairment (dementia and delirium), poor mobility, medications and nutrition can assist in reducing poor outcomes for older people.

Incidents relating to patient falls, slips, trips or near misses are notified under the Falls PIT in ims+. 96 per cent of all fall related incidents recorded within ims+ during the July – December 2021 reporting period resulted in minimal to no harm to the patient.

The CEC Comprehensive Care – Minimising Harm model aligns with the National Safety and Quality Health Service Standards (NSQHSS), Comprehensive Care and Partnering with Consumers standards. Further information on falls prevention can be found on the CEC website.

Medications/IV Fluids

Use of medicines is one of the most common therapeutic interventions across Australian hospitals. It is also the most complex, with delivery of each dose of medicine involving as many as 30 steps and almost as many people.

Capturing specific details of medication related incidents can facilitate accurate reporting and assist in identifying risks and areas for improvement.

The majority of Medication/IV Fluid incidents reported in ims+ during the reporting period (97 per cent) were allocated a Harm Score 3 or Harm Score 4, resulting in minor or no harm to patients. 74 per cent of all medication/IV fluid incidents notified related to the administration and prescription of medications.

Administration related incidents include medications being administered incorrectly, for example an oral medication administered instead of intravenous, the wrong amount given, or medications given at the wrong time. Prescribing related incidents includes illegible writing, incomplete prescriptions or errors made on the prescription.

The CEC’s Medication Safety team supports the safe and quality use of medicines by identifying and addressing emerging medication safety risks as well as monitoring, evaluating and optimising medicines use across NSW. Further information on medication safety can be found here.

Treatment and General Care

The Treatment and General Care PIT is used to identify issues specifically relating to the treatment or care of a patient, and includes treatment that is declined, delayed or inadequate and incorporates accidental injury caused to the patient during medical care.

During the July – December 2021 reporting period, 95 per cent of Treatment and General Care incidents were confirmed as a Harm Score 3 or Harm Score 4. These incidents were further categorised as involving:

  • Inadequate treatment or care (35 per cent)
  • Delayed treatment or care (25 per cent)

Reportable Incident Briefs (RIBs)

In line with the NSW Health Incident Management Policy, confirmed Harm Score 1 incidents are submitted to the NSW Ministry of Health as a Reportable Incident Brief (RIB) within 24 hours of incident notification. Other Harm Score incidents may also be submitted as a RIB as determined by the Chief Executive of the health service.

Figure 6.

Figure 6 - RIBS received by Harm Score

*RIB data obtained from the CEC Patient Safety Database. Data includes all RIBs received from NSW public and private hospitals and St Vincent’s Health Network.

Harm Score 1 Reportable Incident Briefs and SAERs

A Serious Adverse Event Review (SAER) must be undertaken for each Harm Score 1 RIB received, using an approved review methodology. Further details on the review methodologies are located here.

The purpose of the review is to identify any factors that caused or contributed to the incident. Public hospitals are required to submit review findings and recommendations reports to the Ministry of Health within 60 calendar days of the incident notification in ims+. Private hospitals are required to submit SAER reports within 100 days.

The CEC undertakes a review of each SAER received and allocates to a Serious Adverse Event Review (SAER) sub-committee, where the report is reviewed and classified by subject matter experts to identify themes, system wide learning and risks.

Four SAER sub-committees exist within NSW Health. A further two sub-committees were formed during the July – December 2021 reporting period and are referred to as Serious Incident Review (SIR) sub-committees. These sub-committees are shown in Figure 7 below.

Figure 7.

Figure 7 - CRAG

During the current reporting period, a total of 383 clinical RIBs (all Harm Scores) were received by the NSW Ministry of Health. These RIBs were submitted by NSW public and private hospitals and St Vincent’s Health Network. This represents a 5 per cent increase when compared against the preceding six-month period. This may be attributed to the continued submission of COVID-related RIBs and increased hospital activity over the reporting period. An increase in RIBs has been noted over the July – December 2021 reporting period.

Of the 383 RIBs received during the current reporting period, 288 were confirmed as Clinical Harm Score 1. Just under half of these Harm Score 1 RIBs and subsequent SAERs were classified by the Clinical Management sub-committee, which is a broad category that includes incidents related to the diagnosis, treatment and monitoring/observations of patients in any inpatient care setting.

A further 77 Harm Score 1 RIBs and the subsequent SAERs were classified by the Mental Health/Drug and Alcohol sub-committee, which reviews mental health and drug and alcohol related serious incidents, including concerning behaviour and the suspected suicides of mental health clients.

The Maternal and Perinatal sub-committee classified 12 Harm Score 1 SAERs during the reporting period. This sub-committee reviews all serious incidents related to the care of pregnant women before and after birth as well as neonates aged between 0 to 28 days. This also includes stillbirths.

Six Harm Score 1 SAERs were classified by the Child and Young Person sub-committee, which is focused on health care related serious incidents involving children aged between 29 days to 16 years.

62 Harm Score 1 SAERs were classified by the newly formed COVID-19 SIR sub-committee, which reviews all clinical cases including outbreaks and reportable COVID patient deaths.

The Prevention and Response to Violence, Abuse and Neglect (PARVAN) SIR sub-committee was formed during this reporting period. This sub-committee focuses on cases that relate to children, young people and adults who are victims of violence, abuse and neglect. Cases are first reviewed and classified by one of the five sub-committees, before being referred to PARVAN for review and identification of themes. During the reporting period, a single Harm Score 1 SAER was referred to PARVAN.

The breakdown of Harm Score 1 RIBs and the associated SAER classified by SAER/SIR sub-committee is displayed in Figure 8.

Figure 8.

Figure 8 - Harm score 1 RIBS

*Harm Score 1 RIB data obtained from the CEC Patient Safety Database. Includes RIBs received from NSW public and private hospitals and St Vincent’s Health Network.