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Clinical Incident Management The Clinical Excellence Commission Clinical Incident Management in the NSW public health system


Clinical Incident Management in the NSW public health system
 
 
 

A clinical incident is any unplanned event which causes, or has the potential to cause, harm to a patient.


NSW Health staff are required to report all incidents, so that risks to patient safety are recognised and action is taken to prevent recurrence. This is supported by the NSW Health Incident Management Policy (PD2014_004).


The clinical incident reporting system in the NSW public health system is called the Incident Information Management System (IIMS). St Vincent's Health Network uses Riskman.


The IIMS contains all the information collected since statewide clinical incident reporting was implemented in 2005. Thematic analysis enables significant issues, risks and trends relating to clinical care to be identified, so that staff and managers can work together to improve care for all patients. Some of these detailed analyses have been presented as Clinical Focus Reports which are developed in close collaboration with clinicians and are distributed widely, to share learnings and best practice.


Incidents reported in IIMS and Riskman are classified according to a list of Principal Incident Types (PITs), and then further categorised against a Severity Assessment Code (SAC). The key purpose of the SAC is to determine the level of investigation and action required. There are four SAC ratings, ranging from SAC1 (extreme risk) to SAC4 (low risk). All SAC1 incidents are subject to a thorough investigation known as a root cause analysis (RCA), to find out what happened and identify opportunities to make health care services safer (Figure 1).


In addition, the Reportable Incident Brief (RIB) system is designed for the reporting of specific health care incidents to the NSW Ministry of Health. All actual SAC1 incidents and national sentinel events, as outlined in the NSW Health Incident Management Policy (PD2014_004), must be notified via the RIB process. The CEC collates and analyses all clinical RIBs. The following report is informed by both the IIMS reporting system and the CEC RIB database.


CEC's role in incident reporting

As a lead agency for quality and safety improvement in the NSW public health system, the CEC has a key role to play in analysing and reporting on the information provided from the IIMS. In addition, the CEC publishes the outcomes from projects and programs developed in response to clinical incident reporting, such as Between the Flags and SEPSIS KILLS.


The CEC published its first web-based clinical incident management report in 2013, outlining bi-annual data summaries from January 2010 to December 2012. Reports will be provided on a six-monthly basis. Previous reports are available on the CEC website. This work is part of the CEC's commitment to support the NSW health system in providing the safest and highest quality care for every patient.


For more information about the Clinical Excellence Commission, its programs, resources and publications see http://www.cec.health.nsw.gov.au

Included in this report

The information in this report includes data extracted from the IIMS database utilising the IIMS analyser reporting tool, Riskman extracts, Health Information Exchange (HIE) extracts and the CEC RCA review committee classifications. For more specific extract information please contact the CEC Patient Safety Team CEC-patientsafety@health.nsw.gov.au


This report contains:
  • How to interpret the data and information
  • Clinical incident notification data such as principal incident types and the severity of incidents
  • Systems factors in serious clinical incidents identified through root cause analysis
  • Clinical incidents involving
      ▫ Patient identification
      ▫ Falls
      ▫ Medication Safety
      ▫ Paediatrics
      ▫ ICU
  • Complaints notified in the incident information management system and how they are resolved

Data Interpretation


The greatest benefit of IIMS analysis is contained in the narrative, which provides context and highlights issues and system-related opportunities for improvement.

Given the wide variation between services and facilities, accurate comparisons based on notification numbers alone cannot be made. Caution is advised if using IIMS reporting counts or rates as the single source of benchmarking data for a project or program, as many variables influence incident reporting. Lower rates of reporting are not a reliable indicator of safer care. Further qualitative, rather than quantitative, interpretation of the data is therefore recommended.


Figure 1 : Serious clinical incidents requiring RCA investigation
Clinical Incident Management


Clinical Incident Management Notifications

The number of clinical incident notifications in the Incident Information Management System (IIMS), and Riskman for St Vincent’s Health Network, continued the upward trend noted in previous reporting periods with a 33 per cent increase in incident notifications between January 2011 and December 2015 (Table 1).

Severity of Clinical Incidents

Clinical incidents notified in IIMS and Riskman are allocated a Severity Assessment Code (SAC) rating in accordance with NSW Health Incident Management Policy  PD2014_004. The most serious types of clinical incidents are rated as SAC1 (the other possible scores are SAC2, SAC3 or SAC4 in declining order of severity). The key purpose of the SAC is to determine the level of investigation and action required. While an initial SAC may be applied, the actual SAC must be applied within five days of the incident notification. All SAC1 incidents and national sentinel events require a reportable incident brief to be submitted to the NSW Ministry of Health within 24 hours of notification of the incident in the IIMS.

Table 1: Clinical incidents notified in IIMS by Actual SAC rating, January 2011 - December 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS/SVHN Riskman
**SVHN Riskman SAC2-4 data not included July-Dec 2015


The number of SAC1 incidents has decreased since the policy changes in PD2014_004 came into effect. Prior to that, all incorrect patient, procedure or site incidents were classified as SAC1 regardless of severity of harm.

Figure 2 and 3: Clinical SAC1 & SAC2 and SAC3 & SAC4 incident notifications, January 2011 - December 2015

Clinical Incident Management

*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS/SVHN Riskman
**SVHN Riskman SAC2-4 data not included July-Dec 2015

Clinical Incidents per 1,000 Bed Days


Reporting the number of clinical incidents in relation to the activity of the facility (per 1,000 acute bed days) provides a greater insight than number of incidents alone.

Figures 4 and 5 show the number of clinical incident notifications per 1,000 acute care bed days from January 2011 to December 2015. The rate of incidents per 1,000 acute bed days is consistent with previous incident reporting periods (Table 2).  Staff are maintaining a positive reporting culture as the public health system manages escalating demands for acute and increasingly complex care.

Table 2: Clinical incident by SAC notifications per 1,000 acute care bed days, January 2011 - December 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS/SVHN Riskman
**SVHN Riskman SAC2-4 data not included July-Dec 2015

Figure 4 and 5: SAC1 & SAC2 and SAC3 & SAC4 clinical incidents per 1,000 acute care bed days, January 2011 - December 2015

Clinical Incident Management


Principal Incident Type

When a notification of a clinical incident is made, the principal type of incident (PIT) is recorded. There are 19 principal incident types (PITs). The number of notifications per PIT is shown at Table 3 and Figure 6.  From January 2014 to December 2015 the top three PITs have remained consistent with previous reporting periods: Falls, Clinical Management and Medication/IV fluids comprise 47 per cent of the total notifications for the reporting periods.  The order of PITs has not changed over time; however, the number of notifications in the top PITs has increased slightly. This indicates an increase in reporting of falls, clinical management, medication/IV fluid incidents and pressure ulcer (also known as pressure injury), in line with increased bed day data.

Of note, the reporting of pressure ulcers (injuries) has consistently increased due in part to increased awareness, education and reporting culture following the release of the Pressure Injury Prevention and Management policy  PD2014_007, along with the National Safety and Quality Health Service Standards, the Pan Pacific Guideline for the Prevention and Management of Pressure Injury (2012), the International Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (2014)  and the establishment in January 2013 of a statewide working party.


Table 3: Clinical incidents by principal incident type (PIT) as a percentage*, January 2011 - December 2015

Clinical Incident Management
Data obtained from IIMS, excludes St Vincent’s Health Network
*PIT as a % of total PITs for the reporting period
**Other includes categories of nutrition, complaint, security, pathology/laboratory, building/fittings/fixtures/surrounds, and oxygen/gas/vapour

Figure 6: Top four clinical incidents by principal incident type (PIT) as a percentage, January 2013 - December 2015

Clinical Incident Management

The most frequently notified SAC1 incidents from January 2011 to December 2015 continued to be categorised under the PIT of Clinical Management.  This includes incidents associated with diagnosis, patient identification and treatment of patients in any inpatient care setting (Table 4).  The notification rates for the top three SAC2, SAC3 and SAC4 PITs remain consistent as demonstrated in tables 5, 6 and 7.

SAC1 Clinical Management notifications have significantly decreased following the release of the updated NSW Health Incident Management Policy PD2014_004 which no longer requires incorrect patient, procedure or site incidents to be automatically classified as a SAC1 notification. A reportable incident brief (RIB) is still required for all incorrect patient, procedure site incidents regardless of outcome.

Table 4: SAC1 incidents by principal incident type, January 2011 - December 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database
** All clinical streams, includes patient identification errors and retained accountable items (see 'Definitions' TAB)
*** Patient identification reporting requirements changed on 10th February 2014
**** EBM excluded in Jul-Dec 2013 and reported in Incorrect Person Procedure Site data
Other includes RCAs not reviewed, Medication/IV Fluids, Health care associated infection, RCAs not received, Medical device/equipment/property, Blood/Blood Products, Pressure Ulcer, Documentation, Organisational Management/Services, Undetermined cause of death and Mandatory reporting - including deaths in custody
# Includes two patient identification incidents

Table 5: SAC2 incidents by principal incident type, January 2011 - December 2015

Clinical Incident Management
SAC2-4 data obtained from IIMS, excludes St Vincent’s Health Network
*Other includes the categories of Medical device/equipment/property, Organisation management/service, Documentation, Aggression-victim, Accident/occupational health and safety, Blood/blood product, Complaint, Pathology/laboratory, Security, Nutrition, Building/fittings/fixtures/surrounds, and Oxygen/gas/vapour

Table 6: SAC3 incidents by principal incident type, January 2011 - December 2015

Clinical Incident Management
SAC2-4 data obtained from IIMS, excludes St Vincent's Health Network
* Other includes the categories of Documentation, Accident/occupational health and safety, Organisation management/service, Medical device/equipment/property, Aggression-victim, Health care associated infection/infestation, Blood/blood product, Pathology/laboratory, Nutrition, Complaint, Security, Building/fittings/fixtures/surrounds, and Oxygen/gas/vapour

Table 7: SAC4 incidents by principal incident type, January 2011 - December 2015

Clinical Incident Management
SAC2-4 data obtained from IIMS, excludes St Vincent’s Health Network
*Other includes the categories of Behaviour/human performance, Aggression-aggressor, Accident/occupational health and safety, Medical device/equipment/property, Organisation management/service, Aggression-victim, Nutrition, Blood/blood product, Complaint, Pathology/laboratory, Health care associated infection/infestation, Security, Building/fittings/fixtures/surrounds, and Oxygen/gas/vapour


System Factors in Clinical Incidents - Root Cause Analysis

Root Cause Analysis (RCA) investigation is a method used to identify the underlying cause and contributing factors of an incident. It also aims to develop appropriate clinical and management responses and system improvements which could prevent similar incidents in the future. RCA teams include experienced clinicians appropriate for the incident being investigated. All SAC1 clinical incidents (and SAC2, SAC3 or SAC4 incidents deemed to benefit from the RCA process) undergo a RCA investigation. Underlying system failures are often found to have contributed to, or failed to stop, errors during complex care processes.

The CEC reviews all clinical RCA reports through the four RCA review committees; Clinical Management, Maternal and Perinatal and Mental Health/Drug & Alcohol. The RCA review committee classifies each report using a standard taxonomy which has been developed over time. The review and classification of the RCAs help in identifying system-level themes that in turn may have statewide implications. Themes identified through the RCA review have resulted in the development of programs, reports and quality tools including Between the Flags, Sepsis Kills and clinical focus reports.

This report provides further RCA data from the January to June and July to December 2014 reporting periods.

The top three system factors identified by the RCA review committees for the past three years have been communication, care planning and policy and guidelines.

The system factor ‘communication’ relates to both verbal and written formats in any context. This includes: handover between providers or shifts; clinical documentation; communication to patients, families and carers. Poor communication is also a common contributor to incidents in other industries. Indeed, human factors engineers have implemented a range of structured communications strategies in aviation to improve information flow in the cockpit. These strategies are a core component of dedicated human factors training launched by the CEC in 2015.

The system factor ‘care planning’ relates to incidents where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team, including private providers, inpatient and community-based services. Care planning also incorporates incidents which arise when a patient's co-morbidities, falls risk, or the capacity of their carers to manage ongoing care have not been adequately assessed or addressed.

The system factor ‘policy and guidelines’ relates to issues surrounding evidence-based practice in line with NSW Health directives; policy and guideline implementation; understanding; violations and/or workability.


System Factors identified in the Clinical Management RCA Review Committee

The most common system factors identified by the Clinical Management RCA review committee (Table 8) continue to be care planning, communication, and policy and guidelines. These three system factors have consistently remained the top three over the past eight reporting periods.

The number of SAC1 clinical incidents related to system factor notifications per 1,000 acute care bed days remained stable over the January 2011 to June 2015 period. This breaks down to 0.06 to 0.09 SAC1 incidents per 1000 bed days reported (Table 2). However, system factors involving communication, care planning and policy/guidelines were consistently higher during the July to December periods. This correlates with the consistent increase in bed days and separations for those periods.


Table 8: System factors identified through Clinical Management RCA reports, July 2011 - June 2015

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Figure 7: Top three system factors identified through Clinical Management RCA reports, July 2011 - June 2015

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System Factors identified in the Mental Health/Drug & Alcohol RCA Review Committee

Systems factors identified in Mental Health/Drug & Alcohol RCAs demonstrate similar issues to those in clinical management RCAs. Communication, policy and guidelines, care planning and assessment are the top four issues identified (Table 9).

Table 9: System factors identified through review of Mental Health/Drug & Alcohol RCA reports, July 2011 - June 2015

Clinical Incident Management

Figure 8: Top three system factors identified through review of Mental Health/Drug & Alcohol RCA reports, July 2011 - June 2015

Clinical Incident Management
System Factors identified in the Maternal and Perinatal RCA Review Committee

In the January to June 2015 reporting period communication, care planning, observations & monitoring and policy & guidelines, were the most frequent system issues identified by the Maternity and Perinatal RCA committee.


Table 10: System factors identified through Maternal and Perinatal RCA reports, July 2011 - June 2015

Clinical Incident Management

Figure 9: Top three system factors identified through Maternal and Perinatal RCA reports, July 2011 - June 2015

Clinical Incident Management


Risk Factors in RCA Reports


The clinical risk factors in the RCA review process relate to the conditions or situations that patients may be, or have been, exposed to that could increase their risk of serious incident or harm occurring. In August 2013, the taxonomy for reviewing risk factors was refined to be more detailed and provide improved analysis. Tables 12, 13 and 14 highlight the top five risk groups that were identified in the associated RCA committees during January to June 2015 reporting periods.


Table 11: Top 5 risk factors identified through Clinical Management RCA reports, January 2013 - June 2015*

Clinical Incident Management
*Top five risk factors for January - June 2015

Table 12: Top 5 risk factors identified through Mental Health/Drug & Alcohol RCA reports, RCA reports, January 2013 - June 2015*

Clinical Incident Management
*Top five risk factors for January - June 2015

Table 13: Top 5 Risk Factors identified through Maternal and Perinatal RCA reports, January 2013 - June 2015

Clinical Incident Management
*Top five risk factors for January - June 2015

The identification and prompt management of deterioration is a risk factor identified by all RCA committees. The CEC's Between the Flags system addresses the problems associated with failure to recognise, escalate and respond to patient deterioration by providing a suite of standard observation charts which incorporate standard calling criteria to escalate care of the patient. Between the Flags also includes minimum standards for escalation including processes for both Clinical Review and Rapid Response in all NSW Health facilities. The CEC continues to reinforce the importance of early recognition and response to patients who are clinically deteriorating through the organisation's, SEPSIS KILLS and REACH programs.

The RCAs reviewed have identified that patients with acute abdominal pain are at a higher risk of deterioration. The CEC is reviewing in closer detail this type of incident notification and is liaising with specialty groups to develop a clinical focus report to highlight the risk, best practice and recommendations to improve care and management.

The CEC is also undertaking a project entitled Delegation and Escalation at Point of Care with the specific purpose of supporting staff at the bedside to get appropriate senior input in a timely manner for patients.


Patient Identification Clinical Incidents


Patient identification incidents refer to incidents associated with the matching of the correct patient, site and procedure. NSW Health Policy PD2014_036 Clinical Procedure Safety describes the steps that must be taken to ensure that an intended invasive or diagnostic procedure (including surgical operations, endoscopy, dentistry, radiology, nuclear medicine, chemotherapy and radiation therapy procedures) is performed on the correct patient, at the correct site and, if applicable, with the correct implants/prostheses and equipment.

Procedures involving the wrong patient or body part, regardless of the outcome, requires notification to the Ministry of Health as a reportable incident brief (RIB).  These incidents are referred to as patient identification incidents in this report.

Prior to 10 February 2014 all incidents which  involved the incorrect patient, procedure, body part or surgical implant were classified as serious incidents (SAC1) in Incident Information Management System (IIMS) and subsequently underwent RCA investigation.

In 2014, the updated NSW Health Incident Management Policy PD2014_004 mandated that incorrect patient, site, and/or procedure incidents be classified according to actual harm and are not automatically recorded as a SAC1 incident. A formal RCA investigation may not be required, however a reportable incident brief (RIB) to the NSW Ministry of Health remains a requirement.  This is in recognition of the potential serious risk to patient safety inherent in such incidents, although in most cases there is no actual harm caused to the patient.

SAC1 investigations for incorrect patient-related incidents are reviewed to inform work undertaken to strengthen current systems. In the reporting periods January to June 2015 and July to December 2015 there was no significant change in the number of incidents involving incorrect patient, procedure, body part or surgical implant. Reporting of this type of incident continues via RIB to maintain vigilance and awareness for ongoing system improvement. The new changes in SAC rating requirements for incorrect patient, procedure and site incidents are reflected in the decreased January to June 2014 reported data.


Table 14: Location of SAC1 incidents involving patient identification where clinical procedure has occurred January 2011 - December 2015

Clinical Incident Management
*Includes wrong breast milk incidents (Jan 2011 to June 2013)
**Includes EBM previously reported under ward/other
*** Incorrect patient, procedure, site reporting requirements changed 10th February 2014
**** Incidents are already accounted for in the SAC1 data on Table 4

Table 15: Location of SAC2, SAC3 and SAC4 incidents involving patient identification where clinical procedure has occurred January 2014 – December 2015

Clinical Incident Management
* Incorrect patient, procedure, site reporting requirements changed 10th February 2014


Fall Related Clinical Incidents


Patient falls in hospital are a major cause of harm and can result in increased hospital length of stay and increased use of resources. Hospitalised patients more than 75 years of age have a significantly increased risk of falling. They often exhibit frailty, poor mobility and confusion – caused by an unfamiliar hospital environment, acute illness, medications, dementia and/or delirium.

The CEC NSW Falls Prevention Program has supported the implementation of the National Safety and Quality Health Standard 10: Preventing falls and harm from falls. A systemised approach to fall risk screen and assessment with a range of initiatives and resources has been introduced throughout NSW hospitals to prevent falls and the harm associated with falls.


The Severity of Inpatient Fall Incidents

During the reporting periods July to December 2014 and January to June 2015 the number of incidents reporting a principle incident type of fall was 27,879. Of these incidents, 39 were classified as SAC1 and 454 were classified as SAC2 incidents. The SAC1 and SAC2 incidents accounted for 1.7 per cent of all falls notified with the majority of fall events were categorised as a SAC3 or SAC4 event which did not result in serious injury.


Table 16: Falls by SAC rating, January 2011 - June 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS

Figure 10 and 11: Falls by SAC1 & SAC2 and SAC3 & SAC4, January 2011 - June 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS
Type of Falls Incident and Activity at Time of Fall

During the reporting periods July to December 2014 and January to June 2015, the primary type of fall was loss of balance and slips (Figure 12). At the time of the fall, the patients were reported to be moving (42%) or standing (20%) (Figure 13). A further 14 per cent of patients were undertaking activities of daily living, such as unassisted toileting and showering. This is consistent with previous reporting periods.


Figure 12: Type of fall, January 2011 - June 2015

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Figure 13: Activity at time of fall, January 2011 - June 2015

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Figure 14: Falls by age, January 2013 - June 2015

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The Time of Day when Falls Occur

The occurrence of fall incidents notified peaks between 09:00 and 10:59am. During these times patients are more likely to be up and mobilising, attending to personal care and nursing staff are in high demand assisting those patients who are frail and with poor mobility. Additionally, there is significant activity on the wards with clinical handover, ward and medication rounds and diagnostic test requirements. After meal times there is a peak of falls at 0900 - 0959hrs, 1300 - 13590hrs and 1800-1859hrs where there is increased activity by patients attending to their personal toileting needs.


Figure 15: Time of patient falls, January 2013 - June 2015

Clinical Incident Management

The Outcomes of Fall Incidents

Reporting the outcome from a fall is not mandatory. Of the falls incidents with outcomes reported during the January to June 2015 reporting period, 49 per cent of falls reported resulted in no harm to the patient. Twenty-seven per cent resulted in an injury to the patient; including fractures, head injuries, lacerations, bruising, and skin tears which often require intervention and adds to a patient’s length of stay (Table 18).


Table 17: Outcome of fall, January 2011 - June 2015

Clinical Incident Management
Clinical Incident Management


Medication Related Clinical Incidents


The use of medication is the most common interventions in the NSW health care system. During the reporting periods July to December 2014 and January to June 2015, medication incidents were the third most commonly reported clinical incident. The information collected in the Incident Information Management System (IIMS) provides details of the type and classification of medication incidents and the medications involved.


The Severity of Medication Clinical Incidents


During the reporting periods July to December 2014 and January to June 2015, less than half a per cent of medication incidents notified were rated as SAC1 or SAC2 incidents. Sixty-six per cent of all medication incidents received the lowest severity rating (SAC4), a further 30 per cent were identified as SAC3, and the remaining 3.5 per cent represented incidents that had no SAC score applied (Table 18).

Table 18: Medication incidents by SAC rating, January 2011 - June 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS
Includes St Vincent's Health Network data Jan - Dec 2013

Figure 16 and 17: Medication incidents by SAC1 & SAC2 and SAC3 & SAC4 rating by month, January 2011 - June 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS

Table 19: Medication incidents by SAC rating per 1,000 acute care bed days, January 2011 - June 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS. Includes St Vincent's Health Network data Jan - Dec 2013


Type of Medication Related Incident

Consistent with international findings, incidents associated with medication administration are the most commonly reported medication incident type in NSW during 2013, followed by medication prescribing incidents. The CEC Medication Safety and Quality Program aims to reduce administration and prescribing incidents by assisting health care teams to work together to improve their local medicine-use systems.

During the period July 2014 to June 2015, there were 25,468 medications-related clinical incidents notified across NSW (Table 18). Forty-five per cent of incidents with a principle incident type (PIT) of Medication/IV Fluids had an administration-related error recorded, which includes medication being administered incorrectly, for example oral instead of intravenous, in the wrong amount or at the wrong time. Twenty-one per cent of medication incidents were classified as prescribing errors such as illegible writing, incomplete prescriptions or errors made on the prescription itself, and 12 per cent were classified as a dispensing error.

Table 20: Medication incidents by type, January 2011 - June 2015

Clinical Incident Management

*Includes St Vincent's Health Network data Jan - Dec 2013
** A dispensing incident is classified to include those medication incidents that relate to the pharmacist dispensing medication from the pharmacy. An administration incident is classified to include those medication incidents that relate to the provision of the medication to the patient. It is recognised that some staff may be inadvertently using the classifications incorrectly by including administration errors in the dispensing classification.

Medications Involved in Clinical Incidences


Medicines most frequently involved in medication incidents during the period July 2014 to June 2015 included opioids (such as oxycodone, morphine and fentanyl), insulin, and anticoagulant medicines (such as enoxaparin, heparin and warfarin) (Table 21).

During the period July 2014 to June 2015, opioids and anticoagulants were the medications most frequently involved in the more serious (SAC1 and SAC2) medication incidents. These medicines are recognised as high-risk medicines, i.e. those that have a high risk of causing injury or harm if they are misused or used in error. The CEC’s High-Risk Medicines Program aims to heighten awareness of the harm that can be caused by these medicines and provides action-oriented information to assist clinicians in improving their management.


Table 21: Top 15 Medications involved in Clinical Incidents, January 2013 - June 2015

Clinical Incident Management
* Includes St Vincent's Health Network data Jan - Dec 2013
** Includes Oxycodone and Oxycodone sulphate
*** Includes Morphine and Morphine sulphate

Time of Medication Incident


During the period July 2014 to June 2015 the peak time for medication clinical incidents was between 0800-0859hrs, when 15 per cent of incidents occurred, and 2000-2059hrs when a further 10 per cent occurred. The spread of incident time data is consistent from January 2013 to June 2015. These peak medication clinical incidents times are consistent with findings reported in the literature (Roughead and Semple 2009) and correspond with common medication administration times (Figure 18).


Figure 18: Time of Medication incident as a percentage, January 2013 - June 2015

Clinical Incident Management

The Outcome of Medication Incidents


Fortunately, most medication incident notifications are for incidents in which there was no harm to the patient. During the period July 2014 to June 2015, 50 per cent of medication incidents resulted in no negative outcomes. In 25 per cent the outcome was unknown or unspecified. A small proportion (less than 6 per cent) of incidents resulted in patient injury, procedural complication or pathological factor (Table 22).


Table 22: Outcome of Medication Clinical Incidents, January 2014 - June 2015

Clinical Incident Management
* Outcome of incidents is not a mandatory field


Paediatric Quality Care in NSW


The CEC’s Paediatric Quality Program supports and improves the care of infants and children up to 16 years of age (or young people, over 16 years of age still being cared for in one of the three Children’s hospitals within NSW). This program aims to be a centralised point for clinicians regarding paediatric quality and safety.

This Paediatric Quality Program manages the development of paediatric components for all relevant CEC programs, for example, Sepsis Kills, Between The Flags and the Falls Prevention programs.

Severity of Clinical Incidents


The number of SAC1 incidents has decreased in the July to December 2014 to January to June 2015 reporting periods. This coincides with the release of the updated NSW Health Incident Management Policy PD2014_004 which now allows incorrect patient, procedure or site incidents to be classified as a lower score according to the consequence and SAC matrix. The continuous increased number of notifications for less serious incidents (SAC3 and SAC4) suggests incident reporting is embedded into the practice of clinicians and managers in NSW health services. It is also important to note that the age bracket, 0-28 days, also includes a number of maternity-related incidents.


Table 23: Clinical incidents 0-16 years by SAC rating, January 2011 to June 2015

Clinical Incident Management
*SAC1-4 data obtained from IIMS

Figure 19 & 20: Clinical incidents 0-16 years by SAC1 & SAC2 and SAC3 & SAC4, January 2011 - June 2015

Clinical Incident Management
* SAC1-4 data obtained from IIMS

Incidents by age and principal incident type (PIT)


The 0-28 days age bracket consistently reports the largest number of incidents which can be attributed to the inclusion of maternal and birth-related incidents often being reported as 0-28 days.


Figure 21: Clinical incidents 0-16 years by age group January 2011 - June 2015

Clinical Incident Management


The Clinical Management incidents continue to be the most prevalent PIT for the 0-16 year age group and include incidents associated with diagnosis, treatment and patient identification in any inpatient care setting. The CEC continues to promote the importance of paediatric patient safety through programs such as, Falls Prevention Program, Between the Flags and SEPSIS KILLS. Medications/IV fluids is the second most prevalent PIT and includes incidents associated with the administration, prescribing, dispensing, drug count discrepancies, delivery issues and storage of medication/IV fluids. Medication/IV fluids is the focus of the first paediatric specific clinical focus report in 2016.


Figure 22: Top four clinical incidents 0-16 years by principal incident type (PIT), January 2013 - June 2015

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Children and Young Person Root Cause Analysis Review Committee


The CEC established the Children and Young Person (CYP) RCA Review Committee in 2015 to provide specialty-focused classification of RCA reports involving paediatrics. The review and classification of the RCAs help in identifying system-level themes that in turn contributes to the Paediatric Quality Program ongoing work plans.

In 2015, a total of 11 cases were reviewed and the following system level themes have been identified which are consistent with trends observed in the adult RCA Review committee findings.

Table 24: System factors identified through RCA reports, January - December 2015

Clinical Incident Management
*This category allows for multiple results.

Table 25: System Factors sub-categories identified through RCA reports, January - December 2015

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*This category allows for multiple results


Intensive Care Units


The College of Intensive Care Medicine defines intensive care in the ‘Minimum Standards for Intensive Care’ as “… a specially staffed and equipped, separate and self-contained area of a hospital dedicated to the management of patients with life-threatening illnesses, injuries and complications, and monitoring of potentially life-threatening conditions. It provides special expertise and facilities for support of vital functions and uses the skills of medical, nursing and other personnel experienced in the management of these problems. In many units, ICU staff are required to provide services outside of the ICU such as emergency response (e.g. rapid response teams) and outreach services. Where applicable the hospital must provide adequate resources for these activities”

High Dependency Units (HDU) are also specially staffed and equipped, dedicated to the management of patients requiring a higher level of care than can be provided in general wards. There are special staffing arrangements and a concentration of complex equipment. Often, but not always, HDUs are part of the ICU.

There were 45 adult ICU/HDUs in NSW with a total of 627 commissioned beds that include general intensive care, high dependency, coronary care and specialty beds such as neurosurgical and cardiothoracic. There are specific paediatric ICU beds at Sydney Children’s Hospital, Children’s Hospital Westmead and John Hunter Children’s Hospital.

Incident data was extracted for all clinical incident types entered as ‘Intensive Care’ under the Specific Service field for the reporting periods of January to June 2014, July to December 2014 and January to June 2015.

Specific Service is not a mandatory IIMS field for completion, so care should be taken when interpreting this data. It is important to note that the search using Specific Service ‘Intensive Care’ would include all units not separated by their role delineation, service type or patient case-mix (e.g. coronary care units or paediatric units). Clinical incidents notified in IIMS are allocated a Severity Assessment Code (SAC) rating in accordance with NSW Health Incident Management Policy PD2014_004. The most serious types of clinical incidents are rated as SAC1 (the other possible scores are SAC2, SAC3 or SAC4 in declining order of severity) as seen below in table 26. SAC 1 and 2 incidents account for 0.04 per 1000 bed days from January 2015-June 2015 (see table 27).

Table 26: ICU incident notifications by SAC rating, January 2014 - June 2015

Clinical Incident Management
*SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS

Table 27: Clinical incident by SAC notifications per 1,000 acute care bed days, January 2014 - June 2015*

Clinical Incident Management
*There is not sufficient information to completely match the beds related to the incidents and bed days so these numbers should be used as a guide only - Occupied bed days and hours have also been tallied using occupied bed hours of critical care units from the Health Information Exchange data. This is unlikely to completely match specific service identified through the IIMS. The calculation used includes: ICU hours, HDU hours, CCU hours, ICU Neuro hours, HDU Neuro hours, ICU Cardio hours, HDU Cardio hours. Occupied Bed Days is then calculated by dividing the Occupied Bed Hours by 24.
Principal Incident Types

When a notification of a clinical incident is made, the principal type of incident (PIT) is recorded. There are 19 principal incident types (PITs). The number of notifications per PIT is shown at Table 28. From reporting periods, January to June 2014, July to December 2014 and January to June2015 the top three PITs reported have remained consistent. These top three PITs are also represented in those incidents resulting in greatest harm (SAC1-2 incidents).

Pressure Ulcer (injury), Clinical Management and Medication/IV fluids comprise 72 per cent of the notifications in the January to June 2015 reporting period. This is consistent with previous reporting periods. Pressure ulcer is consistently the highest reported incident and accounts for 34 per cent of incidents in the January to June 2015 reporting period. Pressure injuries reported may include injuries already present on admission to ICU.

Representatives from the rural ICU/HDU community recently reviewed pressure injury incidents and found a relationship between devices connected to the patient and reported injuries. Although the incidents reviewed do not represent the same reporting periods in this report, the learning from their findings are important. Work is in progress through the Rural Critical Care Taskforce to reduce this incident type.

Table 28: ICU Clinical Incidents by principal incident type (PIT), January 2014 - June 2015

Clinical Incident Management
Data obtained from IIMS, excludes St Vincent’s Health Network
*Other includes Complaint, Pathology/Laboratory, Aggression-victim, Building/Fitting/Fixture/Surround, Oxygen/Gas/Vapour, Security

Table 29: ICU SAC1 and SAC2 Clinical Incidents by principal incident type (PIT), January 2014 - June 2015

Clinical Incident Management
Data obtained from IIMS, excludes St Vincent’s Health Network *Other includes the categories of Pathology/laboratory, Nutrition, Complaint, Security, Building/fittings/fixtures/surrounds, and Oxygen/gas/vapour
The time of day

The occurrence of ICU incidents notified peaks during the day at 0800hrs and 2100 hours. These times are often when there will be a handover period with staff from both shifts (where 12 hour shifts are available) and handover checking procedures would identify clinical incidents at that time. It may not correlate to the time of incidents occurring. (Figure 23)

Figure 23: ICU incidence by time of incident, January 2014 - June 2015

Clinical Incident Management

Age of patients

The majority of incidents involve patients aged between 55-84 years. This is reflective of the ICU patient median age which is 63 years (ANZICS).

Figure 24: ICU incidence by age of patient, January 2014 - June 2015

Clinical Incident Management

Medication incidents

In ICU medications are often administered intravenously instead of orally and continuous infusions of sedatives, analgesia and other high-risk medicines are often required. These medicines are used for critically ill patients and usually titrated by clinical staff to achieve a prescribed goal, such as blood pressure or sedation level. Many of the infusions are required to be managed precisely due to their rapid and variable effects therefore staff are required to have additional knowledge of the action of these drugs to provide safe and effective care.

The incidents reported under the PIT Medication/IV Fluids were extracted and reviewed to determine which medications were most often notified and at what point in the medication management cycle the incident occurred. The 'top 10' medications involved in medication incidents are included in the High Risk Medicines Management Policy PD2015_029. Narcotics and sedatives make up nearly half of the incidents in the ‘top 10’ list for the period January to June 2015 (Table 30). Heparin and noradrenaline are also represented throughout the reporting periods. Most of the incidents in the ‘top 10’ list relate to intravenous preparations. However, oxycodone and paracetamol incidents were often related to oral preparations and, commonly, the error that occurred was additional doses administered compared to what was prescribed.

Table 30: Medications involved in ICU clinical Incidences, January 2014 - June 2015

Clinical Incident Management
*Multiple responses are allowed in some of the medication incident notification fields and some fields are not mandatory

Table 31: ICU medication incidents by type, January 2014 - June 2015

Clinical Incident Management
*Multiple responses are allowed in some of the medication incident notification fields and some fields are not mandatory
**A dispensing incident is classified to include those medication incidents that relate to the pharmacy dispensing medication from the pharmacy. An administration incident is classified to include those medication incidents that relate to the provision of the medication to the patient. Some staff may be inadvertently using the classifications interchangeably and including administration errors in the dispensing classification.


Complaints and their Resolution

A key priority of the NSW public health system is its focus on patient-based care. Feedback from consumers of health care services, their families and carers is actively encouraged. Complaints received are entered into the Incident Information Management System (IIMS) and Riskman for St Vincent’s Health Network.

Encouraging staff to engage with patients and families during the care experience is known to improve communication, and results in a better experience of care. The CEC’s Partnering with Patients program was established in 2010 to work with local health districts to help include patients and family as care team members, improve consumer engagement and promote safety & quality in health care.

The number of consumer complaints has steadily increased by 2.5 per cent over the reporting periods July to December 2014 and January to June 2015 over the past four years in line with the increase of patient bed days and separations (Figure 25).

When reviewing clinical incident and complaint notifications against occasions of service, the proportion of both clinical incidents and complaints remained constant over time (Figure 25).


Figure 25: Notifications and complaints by NSW separations, January 2011 – June 2015

Clinical Incident Management

Table 32: Complaints by SAC rating, January 2011 - June 2015

Clinical Incident Management

Complaint by Issue Type

The most frequently reported complaint issue type from January 2011 to June 2015 related to treatment, followed by communication and access to a provider, service or hospital bed (Table 33). This is consistent with themes identified in clinical incidents reported by staff. There has been an overall increase in the number of complaints notified in the past four years, which may reflect the adoption of the NSW Health core value of 'openness' across the state.


Table 33: Complaints by issue type, January 2011 - June 2015

Clinical Incident Management
This is not a mandatory field and multiple responses are allowed. The determination of the issue type is made following review of the clinical incident.


Figure 26: Top 3 complaints by issue type January 2011 - June 2015

Clinical Incident Management

The Nature of Complaints


The nature of the complaint is recorded based on the complainant's perception of their experience. Feedback from consumers on their experience in the public health system contributes to ongoing service improvement. The nature of the complaint is a further analysis of the complaint issue type identified from the consumer's perspective. Communication, treatment and access to discharge transport continued to be the area of most dissatisfaction reported during the period January 2011 to June 2015.


Communication

Where communication was the primary issue type reported, the nature of these complaints related to attitude of healthcare staff, inadequate information provided to the patient and/or their carer, and wrong or misleading information provided to the patient and/or their carer (Table 34).


Treatment

Where clinical treatment was the primary issue type reported, the nature of these complaints related to inadequate treatment, coordination of treatment and medication concerns. It is noted that inadequate treatment was approximately three times that of the next highest category (Table 35).


Access

Where access was the primary issue type reported, the nature of these complaints related to delay in admission or treatment, followed by waiting lists, discharge or transfer arrangements and resources and services availability. Access complaints highlight consumers’ concerns about demands on the health care system (Table 36).


Table 34: Nature of complaint about communication, January 2011 - June 2015

Clinical Incident Management
*This is not a mandatory field and multiple responses are allowed

Table 35: Nature of complaint about treatment, January 2011 - June 2015

Clinical Incident Management
*This is not a mandatory field and multiple responses are allowed

Table 36: Nature of complaint about access January 2011 - June 2015

Clinical Incident Management
*This is not a mandatory field and multiple responses are allowed

Resolution of Complaints


The most common forms of resolution for complaints was reported to be through providing an explanation, giving an apology and providing feedback to the clinician who was involved in the complaint (Table 37).


Table 37: Complaint by Resolution Type, January 2011 - June 2015

Clinical Incident Management
* Multiple responses are allowed in the 'resolution type' field and is not a mandatory reporting field

Figure 27: Complaints by top 5 resolution types January 2011 - June 2015

Clinical Incident Management
How the Complaint was received

During January - June 2014, complaints were most commonly communicated directly by telephone (35%), by letter/email (19%) and in person (21%). A small number were received via other entities, including the Health Care Complaints Commission (8%), Minister and Members of Parliament (5%), and Ombudsman (1%). Local heath districts, NSW Ministry of Health, official visitor and other made up the remaining 11 per cent.


Table 38: How the complaint was received January 2014 - June 2015

Clinical Incident Management

Glossary

Acute bed day data

Acute bed day data has been provided to the CEC from the Health System Information and Performance Reporting Branch of NSW Health. The following exclusions have been applied for the reports: (reference for bed types can be found in PD2012_054 Appendix 2)
1) Care type is 0 (Hospital Boarder).
2) Bed types are 25 (Hospital in Home - General), 66 (Delivery Suite), or 67 (Operating Theatre/Recovery).

Clinical incident/incident

Refers to any unplanned event resulting in, or having the potential to result in, harm to a patient.


Complaint - Issue type

The manager’s determination of identified issues after review of the notification. A list of possible types is available within the clinical incident management system for selection. Multiple responses are allowed. This is not a mandatory reporting field.


Complaint - Nature of complaint

A further breakdown of the elements in the issue identified, from the complainants perspective e.g. the issue was communication and the nature was the attitude of staff. A selection list is available within the clinical incident management system for selection. Multiple responses are allowed. This is not a mandatory reporting field.


Human Factors

The field of study concerned with the design of systems or processes to take proper account of the capabilities and limits of the people working within that system.


Incident Information Management System (IIMS)

An on-line incident reporting and management system developed in Australia for NSW Health. The St Vincent's Health Network uses a different system called Riskman.


Incident management

The cycle of activities required to recognise, report, understand and reduce the risk of unplanned events occurring. In the health system, feedback to the notifier and sharing of learnings are essential components of this cycle.


Near-miss

An unplanned event, that did not result in injury, illness, or damage but had the potential to do so. A break in the chain of events prevented harm, due to either staff recognition and action, or a fortuitous event.


Notification

The initial report within IIMS that an incident or near miss may have occurred. All staff are required to report incidents in IIMS and must complete the mandatory fields within the system. Notifications can be anonymous and reflect the information known by the reporter at the time.


Patient Safety Watch

Is a series of focused summary reports based predominantly on incidents which have been subjected to root cause analysis or other investigative methodologies. The aim is to feed the lessons learned back to local health districts and specialty networks, highlighting key risks and recommending preventative actions for local implementation.


Peri-natal

The period shortly before, during and after, the birth of a baby.


Principal Incident Type (PIT)

The classification system within IIMS which assists the incident reporter to describe the incident. This term is often abbreviated to PIT.


Retained accountable items

Unintended material (such as a swab) requiring surgical removal.


Reportable incident brief (RIB)

A document used to notify NSW Health of a reportable incident. RIBs are subject to statutory privilege under section 23 of the Health Administration Act. For more information, NSW Health Incident Management Policy PD2014_004.


Severity Assessment Code (SAC)

The system by which the severity of an incident is rated and the required response is directed across NSW Health services. More information is contained in the NSW Health Incident Management Policy

Abbreviations
CEC Clinical Excellence Commission RCA Root Cause Analysis
EBM Expressed Breast Milk RIB Reportable Incident Brief
eMR Electronic Medical Record SAC Severity Assessment Code
PIT Principal Incident Type VTE Venous Thromboembolism

Principal Incident Type (PIT) Descriptors

Accidents/Occupational Health and Safety

This is used to classify incidents related to accidents, occupational health and safety, or the physical environment and staff incidents. Examples are a needle stick injury, exposure to a hazardous substance; a staff member sustains a burn after spilling a hot drink over their arm, a wet or slippery floor surface.


Aggression

There are two incident types for reporting aggression experienced during health care. These most commonly relate to instances where a patient's verbal communication and/or behaviour to staff or other patients are perceived to be agitated or aggressive in nature. This may be due to the patient's underlying condition, such as confusion, mental illness or physical discomfort. Staff are asked to report about the "aggressor", as this is often an indication of how well the underlying condition is, or can be managed. They are also asked to report all instances where patients, staff or visitors are "victims" of such behaviours. Incidents about patient or staff assaults are also reported under these incident types.


Aggression - Aggressor

This is used to classify the details of the aggressive incident, in the context of the aggressor. Examples are a patient punching another person or a person making physical or verbal threats.


Aggression - Victim

This is used to classify any harm to the victim of an aggressive episode. Examples are a patient being punched by another individual, a victim of a physical or verbal threat.


Anaesthesia

This is used to classify the details of incidents related to anaesthesia delivery. This classification does not capture information related to surgical complications or incidents. These need to be reported separately.


Behaviour/Human Performance

This is used to classify the details of behaviour or human performance incidents. Examples are a patient exhibiting self-harming behaviour or a staff member behaving in a rude or hostile manner.


Blood/Blood Products

This is used to classify the details of incidents related to blood/blood product transfusion processes, dispensing or quality problems. Examples are a patient suffers an anaphylactic reaction to a blood transfusion, a blood unit is mislabelled, blood is stored at the incorrect temperature or an incorrect blood pack is dispensed from the transfusion service.


Buildings/Fittings/Fixtures/Surrounds

This is used to classify the details directly related to a building, including fittings within a building, the fixtures attached and the external surrounds. Examples are poorly designed building/room for its intended purpose, leaky plumbing, loose or insecurely fixed wall mounted appliance, cracked or uneven pathways and power failure.


Clinical Management

This is used to classify the details related to the clinical management of a patient. This includes diagnosis, treatment planning and delivery and ensuring the correct identification of each patient and procedure. Examples are unintended injury during a medical/surgical procedure, procedure performed on the wrong body part or side and delay in diagnosis of patient's condition.


Complaints

This is used if a consumer expressed dissatisfaction about health care services. Examples include a complaint about the care provided or the manner in which it is delivered.


Documentation

This is used to classify the details of an incident involving a problem with any written, typed, drawn, stamped or printed text/information and/or any document into which it has been entered. Examples are a patient's medication chart filed into another patient's medical record, a treatment order is ambiguous or difficult to read and incorrectly labelled specimens.


Falls

This is used to classify details related to a fall. Examples are a patient found on the floor is suspected of having fallen or a disorientated patient fell after forgetting to use his walking frame.


Hospital Acquired Infection/Infestation

This is used to classify the details of infections or infestation acquired during hospitalisation. Examples are a post-operative wound infection or an infected IV (intra-venous) cannula site.


Medical Devices/Equipment/Property

This is used to classify the details directly related to medical devices, equipment or property. Examples are routine maintenance not performed on an autoclave, no diathermy earthing plates available for a theatre procedure or a damaged or faulty patient lifter.


Medication/IV fluids

This is used to classify the details related to medication or intravenous fluid incidents. Examples are medication prescribing errors or incorrect intravenous fluid infusion rates.


Nutrition

This is used to classify the details of nutrition incidents. Examples are a diabetic patient received a non-diabetic meal, the wrong TPN (Total Parenteral Nutrition) formula infused or a patient's nasogastric feed given at 80 mls/hour instead of 40 mls/hour.


Organisation Management/Services

This is used to classify the details of any incident involving the provision of patient, staff and visitor services, or the organisational management of the health care institution. Examples are no hospital beds available, inadequate staff supervision, insufficient staff for workload, inadequate staff facilities or no after-hours kitchen service available.


Oxygen/Gases/Vapours

This is used to classify the details of incidents involving both therapeutic and non-therapeutic use of oxygen and/or other gas. Examples are oxygen administered at 4L/min per minute when it should have been eight or medical air administered instead of oxygen.


Pathology/Laboratory

This is used to describe issues associated with the collection, transport and processing of specimens.


Pressure Ulcer

This is used to classify details of either new pressure ulcers or the worsening of pre-existing pressure ulcers which occur during clinical care. An example is when a bed-bound patient develops a pressure area.


Security

This is used to classify the details of incidents directly related to the security of the organisation. Examples are theft of personal property and bomb scare.

Clinical Incident Management

Contact Us / Feedback


This publication is part of the CEC Incident Management Series.

A complete list of CEC publications is available at www.cec.health.nsw.gov.au

Any enquiries or comments about this publication should be directed to:

Patient Safety
Clinical Excellence Commission
Locked Bag 8,
Haymarket NSW 1240.
Phone: 61 2 9269 5500
Email: CEC-PatientSafety@health.nsw.gov.au

Program and Publication Links
 

Clinical Excellence Commission

 
 
Incident Management reports (Jan 2007-Dec 2010)

Clinical Focus Reports

 
Between The Flags
 

Falls Prevention Program

Medication Safety and Quality

Medication Safety and Quality - High Risk Medicines

Partnering With Patients

Sepsis Kills

 
 
 
NSW Health Policy Directives
 
NSW Incident Management Policy PD 2014_004

NSW Health Clinical Handover - Standard Key Principles PD2009_060