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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

Clinical Incidents

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 (both clinical and corporate), near misses, and complaints so that risks to patient safety are recognised and action is taken to prevent recurrence. This is supported by NSW Health Incident Management Policy - PD2019_034 (Replaces PD2014_004).

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

Since 2005, the IIMS has been used to notify and manage incidents from across NSW public health facilities. Thematic analysis of incident data enables significant issues, risks and trends relating to clinical care to be identified. This facilitates improvement work, ultimately improving the reliability and safety of clinical care being provided to patients. Dissemination of the lessons learned to staff is through regular reports on key findings, in-depth analysis of clinical issues, and focused summary reports including Paediatric Patient Safety Watches.

Incidents reported in the IIMS and Riskman are classified according to a list of Principal Incident Types (PITs), and then further stratified against a Severity Assessment Code (SAC). The key purpose of the SAC is to direct the level of investigation and action required for a particular event. 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). This investigation method identifies root causes, contributing factors and/or systems issues, and recommendations are made to mitigate the risks identified.

Following the identification of a SAC1 incident there is a defined process which takes place, from point of notification and investigation, to open disclosure and analysis of findings, and dissemination of lessons learned. (Figure 1).

The NSW Ministry of Health (MoH) is notified of SAC1 and other significant clinical events through the Reportable Incident Brief (RIB) system. All SAC1 incidents, including national sentinel events, as outlined in the NSW Health Incident Management Policy - PD2019_034 must be notified via the RIB process. Australian Sentinel Events occur infrequently and occur due to system and process deficiencies in our healthcare system. These sentinel events result in death or serious harm. During 2018 there were eight nationally agreed sentinel events, these were:

  1. 1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function
  2. 2. Suicide of a patient in an inpatient unit
  3. 3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure
  4. 4. Intravascular gas embolism resulting in death or neurological damage
  5. 5. Haemolytic blood transfusion reaction resulting from ABO incompatibility
  6. 6. Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
  7. 7. Maternal death associated with pregnancy, birth and the puerperium
  8. 8. Infant discharged to the wrong family

A Revised Australian sentinel events list was endorsed by Australian Health Ministers in December 2018. NSW Health will require the revised NSEs to be notified, via the Reportable Incident Brief System, from 1 July 2019 and investigated accordingly. The Revised NSE definitions now increase the number of NSEs from eight to ten. Maternal death or serious morbidity associated with labour and delivery, and intravascular gas embolism resulting in death or neurological damage have been removed.

The Australian sentinel event list (version 2) 2018 includes:

  1. 1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
  2. 2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
  3. 3. Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death
  4. 4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
  5. 5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
  6. 6. Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward
  7. 7. Medication error resulting in serious harm or death
  8. 8. Use of physical or mechanical restraint resulting in serious harm or death (New)
  9. 9. Discharge or release of an infant or child to an unauthorised person
  10. 10. Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death (New)

The Clinical Excellence Commission (CEC) collates and analyses all clinical RIBs. The following report is informed by IIMS, CEC RIB and RCA databases.

CEC's role in incident reporting

As the lead agency to support patient safety and clinical quality improvement in the NSW public health system, the CEC has a key role in analysing and reporting on the information provided from the IIMS. The CEC has developed a number of projects and programs which have resulted from the analysis incident data in the IIMS, including those focused on the recognition and management of the deteriorating patient (Between the Flags) and addressing patients with sepsis (Sepsis kills).

NSW Health was the first Australian jurisdiction to publically report healthcare incident data. The first report was released in 2005. The CEC published its first web-based clinical incident management report in 2013. Previous reports are available on the CEC website. This regular publication of data is part of the CEC's commitment to be transparent and support the NSW health system in providing the safest and highest quality care for every patient.

Included in this report

The information in this report includes data extracted from the IIMS, the CEC RIB and RCA databases, Riskman and Health Information Exchange (HIE).

For more specific extract information, please contact the CEC Patient Safety Team via email 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 RCA
  • Specific Clinical incidents involving:
    • Patient identification
    • Falls
    • Medication Safety
    • Neonatal / Paediatrics
    • National Sentinel Events
  • Complaints notified in the incident information management system and how they are resolved

Data Interpretation

The IIMS narrative and analysis may provide greater insight into incidents, provide context, and highlight 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, therefore, further qualitative, rather than quantitative, interpretation of the data is recommended.

Figure 1: Serious clinical incidents requiring RCA investigation

Clinical Incident Management

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 - PD2019_034.. 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 a notifier may assign an initial SAC, the actual SAC must be confirmed by a manager within five days of the incident notification. All SAC1 incidents and National Sentinel Events (NSE) require a Reportable Incident Brief (RIB) to be submitted to the NSW Ministry of Health.

While the overall number of incidents is increasing in line with increased activity in NSW hospitals. The data shows that serious incidents in healthcare are extremely rare. Less than two per cent of incidents notified were rated as SAC1 or SAC2, indicating that rates of serious clinical incidents are very low across NSW, and most incidents resulted in little or no harm to the patient involved.

Most reported incidents (95 per cent), were rated as SAC3 or SAC4, and resulted in minimal or no patient harm.

Table 1: Clinical Incidents notified by Actual SAC rating, July 2014 - December 2018

Clinical Incident Management

* SAC1 data obtained from CEC RIB database, SAC2-4 obtained from IIMS/SVHN Riskman

There has been a nine per cent increase in the overall number of clinical incident notifications for July – December 2018 when compared to the previous reporting period. Table 1 identifies that the number of incidents reported in the months July to December are consistently higher than incidents reported during the months of January to June in each calendar year.

Figure 2 and 3: Clinical SAC1 & SAC2 and SAC3 & SAC4 incident notifications, July 2014 - December 2018

Clinical Incident Management

* SAC1 data obtained from CEC RIB database, SAC2-4 obtained from IIMS/SVHN Riskman

Clinical Incidents per 1,000 Acute Bed Days

Reporting the number of clinical incidents in relation to activity i.e. per 1,000 acute care bed days, provides greater insight than the number of incidents alone. The rate of SAC1 and SAC2 incidents from 2014 – 2018 has remained stable. SAC3 and SAC4 incidents that result in little or no harm are in line with the previous reporting period. This demonstrates NSW hospitals have a robust reporting culture and high reliability. The overall rate of incidents per 1,000 acute care bed days is slightly higher for the reporting period July – December 2018 compared with July – December 2017.

Table 2: Clinical Incident notifications by SAC per 1,000 acute bed days, July 2014 - December 2018

Clinical Incident Management

* SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from IIMS/SVHN Riskman

Figure 4 and 5: SAC1 & SAC2 and SAC3 & SAC4 clinical incidents per 1,000 acute care bed days, July 2014 – December 2018

Clinical Incident Management

Principal Incident Type

When notification of a clinical incident is made, a Principal Incident Type (PIT) is recorded in the IIMS which enables the notifier to further categorise the nature of the incident. There are 19 PITs available for selection. Table 3 and Figure 6 display clinical incidents by PIT.

During the July - December 2018 reporting period, the top four PITs have remained consistent with previous reporting periods: Clinical Management, Medication/IV Fluid, Fall and Pressure Ulcer (also known as Pressure Injury). Medication/IV Fluid has replaced Fall as the second most frequently reported PIT during the current reporting period.

Table 3: Clinical Incidents by PIT as a percentage*, July 2014 – December 2018

Clinical Incident Management

Data obtained from IIMS, excludes St Vincent’s Health Network
* PIT expressed as a % of total IIMS incidents for the reporting period
** Other includes categories of building/fitting/fixture/surround, complaint, health care associated infection/infestation, nutrition, oxygen/gas/vapour, pathology/laboratory and security

Figure 6: Clinical incidents by top four principal incident types (PITs) as a percentage of total clinical incident notifications, July 2014 – December 2018

Clinical Incident Management

SAC1 Reportable Incident Briefs (RIBs)

The total number of SAC1 clinical incident notifications has increased by nine per cent over the July – December 2018 reporting period. The rate of SAC1 incidents has remained stable for a number of consecutive reporting periods (refer to Table 2).

The most frequently notified SAC1 clinical incidents from January 2014 to December 2018 continued to be categorised under the PIT of Clinical Management. This includes incidents associated with diagnosis, treatment and monitoring and observations of patients in any inpatient care setting (Table 4).

During review of the Root Cause Analysis (RCA) reports, if the PIT is not clearly identifiable, or the cause of death could not be determined due to unclear circumstances evidence provided, the RCA Review Committee may apply the PIT 'Undetermined cause of death'.

There has been an increase in the number of RCA reports reviewed where no care deficits were evident, and the patient outcome was determined to be non-preventable as these patients often have multiple co-morbidities. Therefore, the RCA Review Committee will apply the PIT of 'Non-preventable outcome'. RCA reports where there is insufficient evidence provided are categorised as 'Unclassifiable'.

Table 4: SAC1 incidents by PIT, July 2014 – December 2018

Clinical Incident Management

* SAC1 data obtained from CEC RIB database
** All clinical streams, includes patient identification errors (see 'Definitions' TAB)
*** Patient identification reporting requirements changed on 10th February 2014
**** Expressed Breast Milk (EBM) excluded in Jul-Dec 2013 and reported in Incorrect Person Procedure Site data
† Other includes Healthcare Associated Infection, Medication/IV Fluid, Medical device/equipment, Decommissioned, Undetermined cause of death and RCAs not received

SAC2-4 IIMS Data

Table 5: SAC2 incidents by principal incident type, July 2014 – December 2018

Clinical Incident Management

SAC2 data obtained from IIMS, excludes St Vincent's Health Network
* Other includes the categories of Accident/occupational health and safety, Aggression-Victim, Blood/blood product, Building/fitting/fixture/surround, Complaint, Documentation, Medical device/equipment/property, Nutrition, Organisation management/service, Pathology/laboratory and Security

Table 6: SAC3 incidents by principal incident type, July 2014 – December 2018

Clinical Incident Management

SAC3 data obtained from IIMS, excludes St Vincent's Health Network
* Other includes the categories of Accident/occupational health and safety, Aggression-Victim, Blood/blood product, Building/fitting/fixture/surround, Complaint, Documentation, Health care associated infection/infestation, Medical device/equipment/property, Nutrition, Organisation management/service, Oxygen/gas/vapour, Pathology/laboratory and Security

Table 7: SAC4 incidents by principal incident type, July 2014 – December 2018

Clinical Incident Management

SAC4 data obtained from IIMS, excludes St Vincent's Health Network
* Other includes the categories of Accident/occupational health and safety, Aggression-Aggressor, Aggression-Victim, Behaviour/human performance, Blood/blood product, Building/fitting/fixture/surround, Complaint, Health care associated infection/infestation, Medical device/equipment/property, Nutrition, Organisation management/service, Oxygen/gas/vapour, Pathology/laboratory and Security
.

System Factors in Clinical Incidents - Root Cause Analysis

A Root Cause Analysis (RCA) is required to investigate every SAC1, and selected SAC2-4, clinical incidents in the NSW Health public health system. The RCA method is used to identify how organisational systems can cause or contribute to clinical incidents. The RCA report findings, and state-wide aggregated analysis, inform system improvements which could prevent similar incidents from occurring in the future. Examples of these include the development of programs, reports and quality tools including Between the Flags, Sepsis Kills, Patient Safety Watches and Clinical Focus Reports.

The CEC reviews all clinical RCA reports through four RCA review committees; Clinical Management, Maternal and Perinatal, Mental Health/Drug & Alcohol (MHDA), Child and Young Person. The RCA Review Committees classify each RCA report using a standard taxonomy. The classification taxonomy is revised as emerging issues and clinical practice changes are identified.

During the reporting period of July - December 2018, the top two system factors identified by the Clinical Management, Maternal and Perinatal RCA and the Mental Health/Drug and Alcohol Review Committees were 'Care Planning' and 'Communication'.

The system factor Care planning pertains to incidents where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team. This includes: care continuity and care co-ordination within a facility or between health care facilities, including private providers, inpatient and community-based services. Care planning also covers incidents which occur when a patient's risk factors including co-morbidities, falls risk, or the capacity of their carers to manage ongoing care, have not been adequately assessed or managed.

The system factor Communication relates to both verbal and written forms of communication. This includes: handover between clinicians or shifts; clinical documentation (including electronic medical record), communication with patients, families and carers and informed consent. Inadequate communication is also a recognised contributor to incidents in other industries.

System Factors identified in the Clinical Management RCA Review Committee

In the July - December 2018 reporting period, 172 Clinical Management RCA reports (all SAC levels) were reviewed and analysed.

The top three system factors identified by the Clinical Management RCA Review Committee (Table 8) relate to Care Planning, Communication and Policy and Guidelines unworkable.

The system factor Policy and Guidelines is applied to incidents where it is identified that there is no policy or guideline; existing policies and guidelines have not been implemented by a staff member or organisation; when a policy or guideline is not in line with NSW Health policy or evidence based practice; if it is not available, unclear or unworkable.

Table 8 outlines the system factors identified in Clinical Management RCAs July 2014 to December 2018 and figure 7 outlines the top three system factors identified through Clinical Management RCAs.

Table 8: System factors identified through Clinical Management RCA reports, January 2014 – June 2018

Clinical Incident Management

Private health facility RCAs are included, when provided by the private facility and represents RCA reports received during the specified reporting period
* ‘No factors identified’ was added as a system factor in January - June 2017

Figure 7: Top three system factors identified through Clinical Management RCA reports, July 2014 – December 2018

Clinical Incident Management

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

In the July – December 2018 reporting period, 93 MHDA RCA reports (all SAC levels) were reviewed and analysed. The data from these RCAs demonstrates that the top two systems factors are consistent across Clinical Management, Maternal and Perinatal and MHDA RCAs. The top three system factors for MHDA were Care Planning, Communication and Assessment.

The system factor Assessment applies to incidents where it is identified that there is a deficiency or gap in the assessment of the patient’s cognitive/ MH status; or a deficiency or gap in the assessment of the triage category in ED; deficiency or gap in the assessment for approved leave from an inpatient unit; a deficiency or gap in the assessment of the patient’s overall physical health and the risk of falls, pressure injuries and venous thromboembolism; and a deficiency or gap in the assessment of the patients risk of harm to others and/ or self- harm or suicide.

Table 9 outlines the system factors identified in MHDA RCAs for the period July 2014 to December 2018, and figure 8 displays the top three system factors identified through analysis of MHDA RCAs for the period July 2014 to December 2018.

Table 9: System factors identified through review of Mental Health/Drug and Alcohol RCA reports, July 2014 – December 2018

Clinical Incident Management

Private health facility RCAs are included, when provided by the private facility and represents RCA reports received during the specified reporting period.
* Changes were made to Mental Health/Drug & Alcohol RCA System Factors in January - June 2017. New categories are now included

Figure 8: Top three system factors identified through review of Mental Health/Drug and Alcohol RCA reports
July 2014 – December 2018

Clinical Incident Management

System Factors identified by the Maternal and Perinatal RCA Review Committee

In the July – December 2018 reporting period, 26 RCA reports (all SAC levels) were reviewed and analysed. This review identified Care Planning, Workforce and Communication as the most frequent system issues affecting care provision. The category of care planning has consistently been the most common system identified in Maternal and Perinatal RCA investigations since 2013. Care planning encompasses issues such as the plan being inadequate to meet the woman/fetus/neonate clinical care requirements, high risk not being considered during care planning and care continuity and coordination being suboptimal.

Of note, while care planning remains the most common system factor, there has been a reduction in this system factor during July – December 2018. This system factor has identified a reduction in the selection of the sub categories; Care Continuity, Care Coordination, High risk not considered and inadequate care plan, by the Maternal and Perinatal RCA Review Committee during classification.

Table 10 outlines the system factors identified in Maternal and Perinatal RCAs for the period July 2014 – December 2018 and Figure 9 outlines the top three system factors identified through Maternal and Perinatal RCAs for the period July 2014 – December 2018.

Table 10: System factors identified through Maternal and Perinatal RCA reports, July 2014 – December 2018

Clinical Incident Management


Private health facility RCAs are included, when provided by the private facility & represents RCA reports received during the specified reporting period.

Figure 9: Top three system factors identified through Maternal and Perinatal RCA reports, July 2014 – December 2018

Clinical Incident Management

System Factors identified in the Child and Young Person RCA Review Committee

The Children and Young Person RCA Review Committee was established in 2016. In the July – December 2018 reporting period, seven RCA reports (all SAC levels) were reviewed and analysed. Care Planning, Policy & Guidelines and Communication were the most frequent system issues identified (Table 11).

Feedback reports in the form of Paediatric Watches have been developed to share the learnings from incident notifications with clinicians across the state.

Table 11 outlines the system factors identified in Child and Young Person RCAs for the period January 2015 to December 2018.

Table 11: System factors identified through Child and Young Person RCA reports, January 2015 – December 2018

Clinical Incident Management

* Included as a systems factor in July - December 2016
** RCA reports involving Paediatric Mental Health were included for the periods July – December 2016 and January - June 2017. All RCAs reviewed at the Child and Young Persons RCA Review Sub-Committee are included, regardless of Primary RCA Committee
*** Excludes RCA Reports involving Paediatric Mental Health for period July - December 2017. Includes RCAs reviewed where Child and Young Persons was identified as being the Primary RCA Sub-Committee

Risk Factors in RCA Reports

The clinical risk factors identified by the RCA Review Committees relate to the conditions or situations that were identified as being a direct cause, or contributing factor, to the incident. In August 2013, the taxonomy for reviewing risk factors was refined to be more detailed and provide improved analysis. Tables 12, 13, 14 and 15 highlight the top five risk groups that were identified in the RCA Review Committees between July 2014 to December 2018 reporting periods.

Table 12: Top five risk factors identified through Clinical Management RCA reports, July 2014 – December 2018*

Clinical Incident Management

* Top five risk factors for July - December 2018
** New category collected January - June 2018

Patients with 'Co-morbidities - Physical' has remained the most common risk factor within Clinical Management RCA reports reviewed and an increase in this risk factor over the July – December 2018 reporting period is evident.

Table 13: Top five risk factors identified through Mental Health/Drug and Alcohol RCA reports, July 2014 – December 2018*

Clinical Incident Management

* Top five risk factors for July - December 2018
** Definitions revised in 2016
*** New category collected from July - December 2016
**** New category collected from January – June 2018
***** Category renamed from Deterioration/management of physical comorbidity as of July - December 2017

'Deteriorating MH-failure to recognise' was the top Clinical Risk factor during the July December 2018 reporting period. This relates to cases in which a patient’s mental health status was deteriorating or there was evidence of decreased level of functioning, or unusual behaviour related to MH status which was not recognised.

Table 14: Top five risk factors identified through Maternal and Perinatal RCA reports, July 2014 - December 2018*

Clinical Incident Management

* Top five risk factors for July - December 2018
** New category collected from January - June 2015
** New category collected from January - June 2018

Table 15: Top five risk factors identified through Child and Young Person RCA reports, January 2015 - December 2018*

Clinical Incident Management

* Top five risk factors for July - December 2018
** RCA RCA reports involving Paediatric Mental Health were included for the periods July – December 2016 and January ‐ June 2017. All RCAs reviewed at the Child and Young Persons RCA Review Sub‐Committee are included, regardless of Primary RCA Committee
*** Excludes RCA Reports involving Paediatric Mental Health for period July 2017 onwards. Includes RCAs reviewed where Child and Young Persons was identified as being the Primary RCA Sub-Committee

The failure to recognise deterioration is a common risk factor identified by all RCA committees. To address the problems associated with these risk groups, the CEC's Between the Flags program provides a suite of standard observation charts which incorporate standard calling criteria which maps clinical parameters to assist in the recognition of deterioration, and when to escalate care of patients. The program 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 SEPSIS KILLS and REACH programs.

Local Health Districts have adopted the implementation of Between the Flags into the electronic medical record. This initiative will assist staff in recognising abnormal clinical observations and deterioration earlier, and subsequently escalate care requirements in accordance with policy.

Patient Identification Clinical Incidents

Patient identification incidents refer to incidents associated with the incorrect matching of the patient, site, procedure, and as applicable implant/prosthesis. The NSW Health policy Clinical Procedure Safety PD2017_032 describes the steps that must be taken to reduce the occurrence of patient identification incidents.

Prior to 10 February 2014 all patient identification incidents were classified as serious incidents (SAC1) in the Incident Information Management System (IIMS), and subsequently underwent Root Cause Analysis (RCA) investigation. In 2014 the NSW Health Incident Management Policy PD2014_004 (replaced by PD2019_034 July 2019) was amended to require the classification of patient identification incidents according to actual harm. Incidents not resulting in harm were no longer automatically recorded as a SAC1 incident.

Procedures involving the wrong patient or body part, regardless of the outcome, require notification to the NSW Ministry of Health as a Reportable Incident Brief (RIB).

In July - December 2018 there was a single SAC1 incident reported in a specialist clinic compared with one in the previous reporting period, which occurred in the operating theatre (Table 16). SAC2-4 incident reports increased by twenty-one per cent compared with the January – June 2018 reporting period (Table 17). These incidents involved mismatching/failure to correctly identify the patient prior to procedures such as diagnostic imaging and pathology tests with the majority resulting in no actual harm to the patient.

Lower rates of reporting are not a reliable indicator of safer care. NSW Health staff are constantly encouraged to report all incidents.

Table 16: Location of SAC1 incidents involving patient identification where clinical procedure has occurred
July 2014 – December 2018

Clinical Incident Management

* Incorrect patient / procedure / site reporting requirements changed 10 February 2014
** Incidents already accounted for in SAC1 data

Table 17: Location of SAC2, SAC3 and SAC4 incidents involving patient identification where clinical procedure has occurred
July 2014 – December 2018

Clinical Incident Management

* Incorrect patient / procedure / site reporting requirements changed 10 February 2014

Fall Related Incidents

Patient falls in hospital can be a major cause of harm, and may result in increased hospital length of stay. Hospitalised patients older than 75 years of age have a significantly higher risk of falling (Figure 10). They often are frail, have poor mobility and may be confused. The confusion can be multifactorial and be secondary to dementia and/or delirium, an unfamiliar hospital environment, acute illness and/or multiple medications.

The CEC Falls Prevention Program supports the implementation of the National Safety and Quality Health Standard 10: Preventing falls and harm from falls. A system-wide approach to fall risk screening and assessment has been introduced in NSW hospitals which includes a range of initiatives and resources to prevent falls and the harm associated with falls.

Leading Better Value Care (LBVC) seeks to identify and implement opportunities for delivering value based care to the people of NSW. Reducing serious harm from falls in hospitals is one of these improvement initiatives.

The Falls Collaborative commenced in October 2017, and, since the inception of this program, a number of Falls Prevention improvement initiatives have been identified within Local Health Districts (LHDs)/ Specialty Health Networks (SHNs).

Figure 10: Falls by age, July 2014 – December 2018

Figure 10

* 'Age of patient' field is not mandatory for completion

The Severity of Inpatient Falls

During the reporting period July – December 2018, the number of incidents with a Principal Incident Type of Fall was 13,831. Of these incidents, 21 were classified as SAC1 and 315 were classified as SAC2 incidents. The SAC1 and SAC2 incidents account for two per cent of all falls notified. It is important to note that the majority of fall events were categorised as SAC3 or SAC4 events which did not result in serious patient harm.

Table 18: Falls by SAC rating, July 2014 – December 2018

Clinical Incident Management

* SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from NSW IIMS

Figure 11 and 12: Falls by SAC1 & SAC2 and SAC3 & SAC4, July 2014 – December 2018

Clinical Incident Management

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

Type of Fall and Activity at Time of Fall

The most frequent type of fall notified during the July – December 2018 reporting period was loss of balance and slips (Figure 13). Forty-one per cent of patients with who fell were recorded as moving and twenty-one per cent were standing when the fall occurred (Figure 14). A further fourteen per cent of patients were undertaking activities of daily living, such as unassisted toileting and showering. This is consistent with data from previous reporting periods.

Figure 13: Type of fall, July 2014 – December 2018

Clinical Incident Management

* 'Fall type' field is not mandatory for completion

Figure 14: Activity at time of fall, July 2014 – December 2018

Clinical Incident Management

* Multiple responses are allowed in the 'activity' field and is not mandatory for completion

Time of Patient Falls

Falls occur most frequently between 09:00 and 11:59 hours. During these times, patients are more likely to be mobilising and attending to personal care activities. Significant activity also occurs on wards during these times with clinical handover, ward/medication rounds and diagnostic testing. Other peak times for falls are 13:00 – 15:59 hours and 18:00-19:59 hours which coincide with increased patient activity and toileting following meal times. It is unclear as to the effect medications may have in contributing to falls at this time e.g. effect on patient taking night sedation.

Figure 15: Time of patient falls, July 2014 – December 2018

Clinical Incident Management

* 'Fall type' field is not mandatory for completion

Outcomes Following a Fall

Of the fall incidents reported during the July – December 2018 reporting period, 49 per cent of falls resulted in no harm to the patient, and 25 per cent resulting in an injury to the patient. These injuries often require intervention.

Table 19: Outcome of fall, July 2014 – December 2018

Clinical Incident Management

* Multiple responses are allowed in the 'outcome' field and is not mandatory for completion. This dataset is generic in nature as it is consistent across all clinical incidents and is not specific to fall related incidents. This dataset is completed by the notifier at the time of incident, and may not be confirmed by the manager.

Caution is advised if using the Incident Information Management System (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 an indicator of safer care, therefore, further qualitative, rather than quantitative, interpretation of the data is recommended.

Medication Related Incidents

The prescription and administration of medication continues to be one of the most frequent activities in the NSW public health system. During the reporting period July – December 2018, medication incidents were the second most commonly reported clinical incident. It is important to note that over 99 per cent of these incidents resulted in either little or no harm to patients. The information notified 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 Incidents

During the reporting period July – December 2018, less than half of one per cent (0.42%) of medication incidents notified were rated as SAC1 or SAC2 incidents. Sixty-three per cent of all medication incidents received the lowest severity rating (SAC4), a further 33 per cent were identified as SAC3, and the remaining represented incidents with no SAC score applied (Table 20). This finding is consistent with the previous reporting period.

Table 20: Medication incidents by SAC rating, July 2014 – December 2018

Clinical Incident Management

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

Figure 16 and 17: Medication incidents by SAC1 & SAC2 and SAC3 & SAC4 rating, July 2014 – December 2018

Clinical Incident Management

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

Table 21: Medication incidents by SAC rating per 1,000 acute care bed days, July 2014 – December 2018

Clinical Incident Management

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

Type of Medication Incident

During the reporting period July - December 2018, there were 14,295 medication-related notifications (Table 20). IIMS captures where in the medication management cycle the incident occurred. Medication administration continues to be the most frequently reported medication process involving an incident, followed by prescribing, which is consistent with international findings.

The CEC Medication Safety and Quality Program aims to reduce administration and prescribing incidents by assisting health care teams to improve their local medicine-use systems.

Thirty-nine per cent of medication related incidents include medications being administered incorrectly, for example an oral medication administered instead of intravenous, the wrong amount given, or at the wrong time. Eighteen per cent of notified incidents were prescribing errors which includes illegible writing, incomplete prescriptions or errors made on the prescription (Table 22).

Table 22: Medication incidents by type, July 2014 – December 2018

Clinical Incident Management

* Multiple responses are allowed in the 'medication problem type' field and is not mandatory for completion
** A dispensing incident is classified to include those medication incidents that relate to the pharmacy dispensing medication. An administration incident is classified to include those medication incidents that relate to the provision of the medication to the patient. However it is accepted that some staff may be inadvertently using the classifications incorrectly by including administration errors in the dispensing classification.

Type of Medications Involved

The most frequent medications involved in incidents during the reporting period July – December 2018 included opioids (such as oxycodone, morphine, fentanyl, hydromorphone and methadone) paracetamol, insulin, benzodiazepines (such as diazepam and midazolam) and anticoagulant medicines (such as enoxaparin and heparin) (Table 23).

Opioids, insulin and anticoagulants 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 potential harm that could be caused by these medicines and provides action-oriented information to assist clinicians in improving their management of high-risk medicines.

Table 23: Top 15 Medications involved in Clinical Incidents, July 2014 – December 2018

Clinical Incident Management

* Multiple responses are allowed in the 'medication involved' field and is not mandatory for completion
** Includes Oxycodone and Oxycodone Hydrochloride
n/a - Data not available

Time of Medication Incident

During the reporting period July – December 2018, the peak time for medication related incidents continued to be between 08:00-08:59 hours, when 14 per cent of incidents occurred, and between 20:00-20:59 hours when a further eight per cent of incidents occurred. The most frequent time of medication related incidents is consistent with previous reporting periods (Figure 18) and corresponds with the literature (Roughead and Semple 2009).

Figure 18: Time of Medication incident as a percentage, July 2014 – December 2018

Clinical Incident Management

* 'Time of Incident' field is not mandatory for completion

The Outcome of Medication Incidents

During the reporting period July – December 2018, 51 per cent of medication related incidents did not result in patient harm. In 23 per cent of incidents, the outcome was unknown or unspecified. Six per cent of incidents resulted in pathophysiological outcome/disease related factors (for example asthma, reddened area, confusion or disorientation), procedural complication or patient injury (Table 24).

Table 24: Outcome of Medication Incidents, January 2014 – December 2017

Clinical Incident Management

* Multiple responses are allowed in the 'outcome' field and is not mandatory for completion. This dataset is generic in nature as it is consistent across all clinical incidents and is not specific to medication related incidents. This dataset is completed by the notifier at the time of incident, and may not be confirmed by the manager.

Caution is advised if using the Incident Information Management System (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 an indicator of safer care. Further qualitative, rather than quantitative, interpretation of the data is recommended.

Paediatric Quality Care in NSW

There are 1.6 million children and young people aged 0-17 years who live in NSW, compromising approximately 23 per cent of the state’s population1. In 2017, there were nearly 2.9 million Emergency Department visits to NSW public hospitals, with 22 per cent  of these visits being children2. Additionally there were nearly 2 million inpatient admissions with children representing close to 12 per cent of all inpatient admissions3. Approximately 1 in 10 clinical incidents reported in the Incident Information Management System (IIMS) involves children and young people under 20 years of age. The Paediatric Patient Safety Program focuses on children over the age of 29 days and have been discharged from maternal and perinatal services. The program works across a range of areas to improve the quality and safety of health care for children and young people in NSW. The program is the centralised point of information for paediatric quality and safety for clinicians in the NSW public health system.

The program works in collaboration with other programs including Sepsis Kills, Between the Flags, Medication Safety, Pressure Injury Prevention, End of Life Care and Falls Prevention to improve the quality and safety of health care for children and young people in NSW.

During the reporting period July – December 2018, less than two per cent of all paediatric incidents notified were rated as SAC1 or SAC2. Forty-nine per cent of all paediatric incidents received the lowest severity rating (SAC4), a further 44 percent were allocated a SAC3 and the remaining five per cent represented incidents with no allocated SAC score. Table 25 outlines the final SAC allocation for all incidents involving patients aged between 0 and 16 years of age.

The SAC1 data includes the neonatal age group (0-28 days). This incorporates all babies admitted to neonatal units and special care nurseries post-delivery and is not included in paediatric service provision. Included in the paediatric IIMS data set (SAC1-4) are those neonates in Neonatal Intensive Care Units (NICUs), neonatal special care nurseries and birthing units. The ‘0 to 28 days’ age band have a larger number of incidents due to the acuity and complexity of this group of patients. A significant number of babies within this age group are under the care of maternity and neonatal services.

Table 25: Clinical incidents 0-16 years by SAC rating, July 2014 – December 2018

Clinical Incident Management

* SAC1 data obtained from CEC RIB database, and includes notifications for all patients aged between 0 and 16 years of age, and excludes stillbirths. SAC2-4 data obtained from IIMS where the ‘age band’ field identified the age of the patient between 0 and 16 years. The ‘age band’ field is not mandatory for completion.
Note: Included in the paediatric data set (SAC1-4) are those neonates in NICUs, neonatal high dependency and birthing units, which sits outside the scope of the Paediatric Patient Safety Program.

Figure 19 and 20: Clinical incidents 0-16 years by SAC1 & SAC2 and SAC3 & SAC4, July 2013 – December 2017

Clinical Incident Management

* SAC1 data obtained from CEC RIB database and includes notifications for all patients aged between 0 and 16 years of age, and excludes stillbirths.
SAC 2-4 data obtained from IIMS

Incidents by age and principal incident type

The '0 to 28 days' age band consistently reports the largest number of incidents. This can be attributed to the inclusion of maternal and birth-related incidents often being reported as being within the '0 to 28 days' age band (Figure 21).

Figure 21: Clinical incidents 0-16 years by age group July 2014 – December 2018

Clinical Incident Management

*‘Age Band’ is not a mandatory field for completion

Note: Included in the paediatric data set (SAC1-4) are those neonates in NICUs, neonatal high dependency and birthing units, which sits outside the scope of the Paediatric Patient Safety Program.

Clinical Management continues to be the most prevalent Principal Incident Type (PIT) amongst paediatric related incidents and includes incidents associated with diagnosis and treatment.

Medication/IV fluid continues to be the second most prevalent PIT (Figure 22) and includes incidents associated with the administration, prescribing, dispensing, drug count discrepancies, delivery issues, and storage of medication/IV fluids. In planning, the Paediatric Patient Safety Program will be working with the Medication Safety Team at the CEC on the use and storage of patient’s own Adrenaline auto injector when in hospital for patients with known anaphylaxis. This will aim at reducing delays to treatment for patients who experienced an anaphylactic reaction while in hospital.

The Paediatric Clinical Pearls of Wisdom was released in August 2018. This resource is targeted towards junior clinicians, and was developed by senior clinicians on "things I wish I knew as a junior clinician". A similar resource for parents is being created and plans for the future include expanding the Paediatric Clinical Pearls of Wisdom to specialties such general surgical, and gastroenterology.

Figure 22: Clinical incidents 0-16 years by top four principal incident types (PIT), July 2014 – December 2018

Clinical Incident Management

Children and Young Person RCA Review Committee continues to provide specialty focused classification of RCA reports involving paediatric patients. In the period July – December 2018 there were seven RCAs reviewed by the Children and Young Person RCA Review Committee and in the period January – June 2018 there were six RCAs reviewed

Further information regarding the outcomes of this committee can be viewed on the RCA tab of this report.

The CEC's Paediatric Patient Safety Program continues to develop pediatric patient safety information bulletins entitled Paediatric Watch – Lessons from the frontline. These information brochures provide front line clinical staff with learnings from serious incidents and highlight opportunities to improve care for children and young people

References

  1. Source: 2011 Census of Population and Housing, Australian Bureau of Statistics.
  2. Source: Emergency Department Data Collection, Secure Analytics for Population health Research and Intelligence (SAPHaRI), Centre for Epidemiology and Evidence, NSW Ministry of Health, downloaded on 25-Sep-2018.
  3. Source: Admitted Patient Data Collection, Secure Analytics for Population Health Research and Intelligence (SAPHaRI), Centre for Epidemiology and Evidence, NSW Ministry of Health, downloaded on 25-Sep-2018.

National Sentinel Event (NSE)

In 2002, Australian states and territories agreed to ongoing contribution to a set of eight core sentinel events which have been reported nationally since 2004. Sentinel Events are adverse events that result in death or serious harm to a patient and are considered to be preventable. Public reporting against these Events was considered to be an opportunity for jurisdictions to share learnings about these Events, and to reduce the risk of their recurrence. It is important to note that these Sentinel Events occur infrequently, and, are often due to system and process deficiencies in our healthcare system, and result in the death of, or serious harm to the patient.

The eight agreed Sentinel Events are:

  1. 1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function
  2. 2. Suicide of a patient in an inpatient unit
  3. 3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure
  4. 4. Intravascular gas embolism resulting in death or neurological damage
  5. 5. Haemolytic blood transfusion reaction resulting from ABO incompatibility
  6. 6. Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
  7. 7. Maternal death associated with pregnancy, birth and the puerperium
  8. 8. Infant discharged to the wrong family.

It is important to note that Australian jurisdictions interpret these sentinel events differently. NSW has adopted a broad interpretation of these events and, as a result, caution is required in interpreting this data.

Commencing in 2007,sentinel events have been reported by each Australian jurisdiction for inclusion in the Productivity Commission's Report on Government Services (ROGS). The ROGs report provides information on the effectiveness and efficiency of government services in Australia, and contains data which are published annually on the equity, efficient and cost effectiveness of government services. NSW sentinel event data is displayed at Table 26.

Suicide of a patient in an inpatient unit

There has been a decrease of 56 per cent in inpatient suicides from 9 in 2015/16 to 4 in 2016/17. It is important to note that the NSW definition of events in this category is broader than the Australian Commission for Safety and Quality in Healthcare's (ACSQHC) definition and includes patients on approved leave and those who have absconded from care.

Retained material

There has been an 11 per cent decrease in retained instruments or other material requiring re-operation or further surgical procedure from 2015/16 to 2016/17.

Medication Safety

Since 2013/14 NSW public hospitals have responded to the need to drive improvements in medication safety with support from the Clinical Excellence Commission by establishing and implementing dedicated improvement programs focused on high-risk medicines and anticoagulants.

Some of the strategies include:

  • Released Newer Oral Anticoagulants (update) Safety Notice, March 2014
  • Released Ten-fold Medication Dosing Errors Patient Safety Watch, April 2014
  • Established the CEC Anticoagulant Working Party, June 2014
  • Updated the High-Risk Medicines Management Policy PD2015_029, August 2015
  • Safety Notices on newer oral anticoagulants and ten-fold medication dosing errors have been released
  • Additionally, a CEC anticoagulant working party has been established, and updates and re-release of NSW Health High-Risk Medicines Management Policy PD2015_029 includes the management of anticoagulants

For the 2016/17 period, there has been a 50 per cent decrease of medication errors resulting in death due to incorrect administration of drugs.

Maternal deaths

There has been a 33 per cent decrease in the number of maternal deaths associated with pregnancy, birth or the puerperium in the 2016/17 reporting period when compared to 2015/16. Note the definition was altered in the 2014/15 reporting period to include both the antenatal and post-natal periods, whereas the previous definition included delivery only. Subsequently, data relating to the 2014/15 and 2015/16 financial years are not comparable to any results previously published.

The Australian Commission on Safety and Quality in Health Care is undertaking a Review of the National Sentinel Events List on behalf of the states, territories and the Commonwealth.

Table 26: NSW selected Sentinel Events (*)

Clinical Incident Management

(a) Sentinel Events definitions can vary across jurisdictions.
(b) Data for reporting periods prior to 2016-17 include events that occurred in private hospitals and day procedure centres and are therefore not comparable with data for 2016-17
(c) Data are sourced from the NSW Maternal and Perinatal Mortality Review Committee. Data for all prior years included in the table have been updated to reflect the modified definition, and are therefore not comparable to results published in the 2014 Report and prior versions. National Sentinel Event data for FY2016/17 will be provided early 2019. Source: Report on Government Services 2018, Chapter 12, Volume E

Table 27: Australian Total selected Sentinel Events (*)

Clinical Incident Management

(a) Sentinel Events definitions can vary across jurisdictions, and are therefore not comparable.
(b) The total includes sentinel events for the ACT which are not reported in the 8 sub categories of sentinel events due to confidentiality issues
National Sentinel Event data for FY2016/17 will be provided early 2019.
Source: Report on Government Services 2018, Chapter 12, Volume E

Complaints and their resolution

The key priority of the NSW public health system is its focus on patient-centred care. Feedback from consumers, their families and carers about their health care experiences is actively encouraged. Complaints received are entered into the Incident Information Management System (IIMS).

Encouraging staff to engage with patients and families during care delivery 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 and quality in health care.

The number of consumer complaints for July – December 2018 has decreased by less than two per cent compared with the preceding 6 month period.

When reviewing clinical incident and complaint notifications against occasions of service, the proportion of both clinical incidents and complaints has remained consistent over time (Figure 23).

Figure 23: Notification of clinical incidents and complaints by NSW separations, July 2014 – December 2018

Clinical Incident Management

During he reporting period, less than one per cent of complaints notified were classified as a SAC1 or SAC2 incident. The majority, 74 per cent, of complaint notifications were categorised as a SAC4 severity rating, with a further 24 per cent allocated a SAC3 rating. One per cent of complaints received were not assigned a SAC score at the time of data extraction (Table 28).

Table 28: Complaints by SAC rating, July 2014 – December 2018*

Clinical Incident Management

* All data obtained from IIMS and excludes St Vincent's Health Network

Complaint by issue type

The most frequently reported complaint type for July – December 2018 relates to treatment, followed by communication and then access to a provider, service or hospital bed (Table 29). This is consistent with themes identified in clinical incidents reported by staff.

Table 29: Complaints by issue type*, July 2014 – December 2018

Clinical Incident Management

* Multiple responses are allowed in the 'issue type' field and is not mandatory for completion. The determination of the issue type is made following review of the complaint

Figure 24: Top three complaints by issue type, July 2014 – December 2018

Clinical Incident Management

The nature of complaints

The nature of the complaint identifies, from the consumer's perspective, what the care delivery issues and concerns were about. Treatment, communication, and access were the three most frequently reported complaint issues for this reporting period. This is consistent with data from previous reporting periods.

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. complaint in treatment.

Table 30: Nature of complaint about treatment*, July 2014 – December 2018

Clinical Incident Management

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

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 31).

Table 31: Nature of complaint about communication*, July 2014 – December 2018

Clinical Incident Management

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

Access

Where access was the primary issue type reported, the nature of these complaints related to delay in admission or treatment, followed by discharge or transfer arrangements, resources/service availability and waiting lists. Access related complaints highlight consumers’ concerns about demands on the health care system (Table 32).

Table 32: Nature of complaint about access*, July 2014 – December 2018

Clinical Incident Management

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

Resolution of complaints

The top five most common forms of complaint resolution remain consistent with previous reporting periods and include; giving an apology, providing an explanation, and providing feedback to the clinician who was involved in the complaint (Table 33).

Table 33: Complaint by resolution type*, July 2014 – December 2018

Clinical Incident Management

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

Figure 25: Complaints by top five resolution types, July 2014 – December 2018

Clinical Incident Management

How the complaint was received

During the July – December 2018 reporting period, complaints were most commonly communicated directly by telephone (32%), by letter/email (23%) and in person (18%). This has been a constant theme across all previous reporting periods. A small number were received via other entities, including the Health Care Complaints Commission (7%), NSW Minister and Local Health Districts and Specialty Health Networks(4%) and by a Member of Parliament (2%). The remaining ten per cent comprises complaints received by the NSW Ministry of Health, Official visitors, the NSW Ombudsman, Other State Government Department, Health Insurance Commission, the NSW State Coroner, and 'Other' not listed.

Table 34: How the complaint was received*, July 2014 – December 2018

Clinical Incident Management

* Multiple responses are allowed in the 'complaint received' field and is not mandatory for completion

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:
1) Care type is 0 (Hospital Boarder).
2) Bed types are 25 (Hospital in Home - General), 66 (Delivery Suite), or 67 (Operating Theatre/Recovery).

(reference for bed types can be found in PD2012_054 Appendix 2)

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 complaint notification. A list of possible types is available within the incident information management system (IIMS) for selection. Multiple responses are allowed. This is not a mandatory reporting field.

Complaint - Nature of complaint

A further analysis of the complaint issue type from the complainant’s perspective e.g. the issue was communication and the nature was the attitude of staff. A selection list is available within the 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 online 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

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.

Perinatal

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 notifier 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 refer to the NSW Health Incident Management Policy PD2014_004. (as of July 2019 replaced by PD2019_034).

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 PD2014_004. (as of July 2019 replaced by PD2019_034)

Abbreviations

CEC Clinical Excellence Commission PIT Principal Incident Type
EBM Expressed Breast Milk RCA Root Cause Analysis
eMR Electronic Medical Record RIB Reportable Incident Brief
IIMS Incident Information Management System SAC Severity Assessment Code

Principal Incident Type (PIT) Descriptors

Accident/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.

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 absconding from hospital grounds.

Blood/Blood Product

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.

Building/Fitting/Fixture/Surround

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.

Complaint

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.

Fall

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.

Health Care Associated 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 Device/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 fluid

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/Service

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/Gas/Vapour

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 injuries or the worsening of pre-existing pressure injuries which occur during clinical care. An example is when a bed-bound patient develops a pressure injury.

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.