Biannual incident report

July – December 2024

Keeping Patients Safe: Incident Management in NSW Health

An incident is an unplanned event that results in, or has the potential for, injury, damage or loss. This includes near misses, where harm was avoided but could have occurred. An incident may also be referred to as an ‘adverse event’. ¹

NSW Health is committed to learning from incidents to improve safety across the health system. Staff are required to report all incidents involving patients (also known as clinical incidents), workers and visitors, as well as near misses, and consumer feedback. This helps identify risks to patient safety and supports action to prevent similar events from happening again.

This commitment to patient safety is supported by the NSW Health Incident Management Policy PD2020_047.

NSW Health has reported incident data since 2005, when the Incident Information Management System (IIMS) was introduced. In 2019, a new system, ims+, was progressively rolled out across NSW Health facilities. St Vincent's Health Network (SVHN) use a different system, Riskman, for their incident reporting.

When a patient-related incident is reported in ims+, it is assigned a Harm Score to reflect the severity of the outcome for the patient and any additional care required due to the incident. The Harm Score directs the level of investigation, with four Harm Score ratings ranging from Harm Score 1 (serious harm) to Harm Score 4 (no harm or near miss).

All Clinical Harm Score 1 incidents undergo a Serious Adverse Event Review (SAER) to understand what happened, why it happened and how to prevent it in future. These reviews identify factors that caused or contributed to an incident and provide recommendations to reduce identified risks. Local Health Districts (LHDs) and Specialty Health Networks (SHNs) track these actions, and lessons are shared across the health system.

Figure 1 provides the framework for the review process for incidents requiring a SAER during the July – December 2024 reporting period.

The NSW Ministry of Health (MoH) is notified of Harm Score 1 incidents, including Australian Sentinel Events (ASEs), and other significant clinical incidents through a Reportable Incident Brief (RIB).

Sentinel Events are rare, preventable events that result in serious harm or death to a patient. Ten ASE types have been nationally defined and reported since July 2019. More information on Sentinel Events is available from the Australian Commission on Safety and Quality in Health Care website.

Figure 1: Serious clinical incidents requiring SAER investigation during the period July – December 2024.

The CEC's role in Incident Reporting

The Clinical Excellence Commission (CEC) is the lead agency supporting patient safety and clinical quality improvement in the NSW public health system. One of its key roles is to monitor and analyse clinical incident data reported to identify priority areas for improvement.

Through its programs and expertise, the CEC supports patient safety across NSW in areas such as:

• Recognition and management of the deteriorating patient,
• Sepsis management,
• Comprehensive care Minimising Harm model,
• Patient and family escalation through REACH (Recognise, Engage, Act, Call, Help is on its way),
• Infection Prevention and Control (IPAC)
• Therapeutics safety
• Care of specific patient groups e.g. Maternity and fetal safety, Neonatal Safety, Paediatric safety

NSW was the first state in Australia to publicly report healthcare incident data, starting in 2005. The CEC published its first online clinical incident report in 2013. Ongoing reporting reflects the CEC's commitment to be transparent, accountable and supportive of NSW Health clinicians and staff to provide safe, high quality care for every patient, every time.

References

¹Organisation for Economic Co-operation (OECD) (2017).