Nearly two million people receive care in NSW public hospitals every year, where the standards of care are among the best in the world. As is the case with every health system, occasionally an unplanned event occurs that causes harm, or has the potential to cause harm. This is known as a clinical incident.
NSW Health staff members are required to report all identified clinical incidents, near misses and complaints in the state-wide Incident Information Management System (IIMS). It is one of the world's largest clinical incident reporting systems, with over 140,000 incidents reported and 600 root-cause analyses (RCAs) completed annually.
Each NSW Health entity is required to have in place a system to manage incidents based on the following principles:
Openness about failures - incidents are reported and the incident acknowledged without fear of inappropriate blame. Patients and their families/support persons are offered an apology and told what went wrong and why
Emphasis on learning - the system is orientedtowards learning from mistakes and consistently employs improvement methods for achieving this
Obligation to act - the obligation to take action to remedy problems is clearly accepted and the allocation of this responsibility is unambiguous and explicit
Accountability- the limits of individual accountability are clear, individuals understand when they may be held accountable for their actions
Just culture - individuals are treated fairly
Appropriate prioritisation of action - action to address problems is prioritisedand resources directed to those areas where the greatest improvements are possible
Cooperation, collaboration and communication - teamwork is recognised as the best defence of system failures and is explicitly encouraged and fostered withina culture of trust and mutual respect.
The NSW Health Incident Management Policy PD2014_004 provides more details on how incidents are managed in NSW Health facilities.
NSW Health employees can submit patient safety incidents here
Templates for conducting a root cause analysis are available here
The following incident investigation resources are available for Falls