Patient Safety, Incident Management and Open Disclosure

Principles of Patient Safety

Ensuring patient safety is important to health care professionals, patients and the community, and is a key component of the Hunter New England Health Clinical Governance Framework. There are growing community and professional expectations that accountability for the safe delivery of health services will be openly demonstrated. The current understanding, which is still relatively recent, is that addressing systems issues is the primary basis of achieving quality improvement. Today, patient safety is managed, monitored and evaluated by creating an environment that promotes use of best evidence in patient care and encourages data-based decision-making; by having robust systems to identify incidents and risks; by monitoring, evaluating and reporting on quality outcomes; and by encouraging staff and patients to provide feedback and input into the quality and safety agenda.

The basic principles of patient safety are as follows:

Focusing on system issues and change management;
Moving away from a blame culture that focuses on individuals when incidents occur, to one that recognises the impact of systems errors;
Understanding cause and error, including the complex human factors involved in clinical care;
Using and valuing adverse events, errors, incidents and near misses as flags to improve health care systems, and
Promoting a culture of openness in which errors are acknowledged and openly discussed with patients and their families.

Incident Management

Incident management is an important component of the NSW Health and HNE Health Safety and Clinical Quality programs. In 2004, NSW Health introduced a statewide incident management system, supported by a statewide electronic incident reporting tool known as the Incident Information Management System (IIMS). IIMS is implemented under a policy framework to guide the notification, prioritisation, investigation, analysis and action and feedback of health care incidents using the Severity Assessment Code (SAC) system.

All serious clinical incidents (SAC1) are reported to the NSW Department of Health via a Reportable Incident Brief (RIB) process coordinated by Clinical Governance, and are investigated in detail using Root Cause Analysis (RCA) methodology. Since 1 August 2005, legislation has required all Clinical SAC 1 incidents to be investigated using the RCA methodology.

Identification and Investigation of Incidents

1. Identification
Adverse events and incidents can be identified by using a suite of strategies such as:

Facilitated Incident reporting – IIMS (Incident Information Management System)
Medical Record Reviews
Effective use of clinical Indicators
Peer review

2. Notification
All clinical incidents must be notified in the electronic Incident Information Management System (IIMS). This system is easily accessible to clinical staff and managers through the HNE Health intranet, and staff are encouraged to report incidents that arise.

3. Prioritisation
Incidents are recorded and classified according to consequence and likelihood of occurrence using the Severity Assessment Code

Serious adverse events and incidents must be reported to NSW Health. This is undertaken in the form of a Reportable Incident Brief (RIB), which is forwarded by the relevant manager to Clinical Governance, and reviewed and approved by the Chief Executive.

4. Investigation
All SAC 1 incidents require an Root Cause Analysis (RCA) review, which is an analysis of the event to determine any root causes of the event. Safety Improvement Program training is available to HNE Health staff to develop these Root Cause Analysis investigation skills. Open disclosure to the patient and/or their family is an important component of the preparation to undertake root cause analysis.

All SAC 2 incidents must have a detailed investigation by the relevant senior manager.

All SAC 3 /SAC 4 incidents must be investigated at the local management level. As well as the investigation at the local level, monitoring of trended or aggregated data should be used to identify and prioritise issues.

Recommendations must be made to address root causes of the incident and responsibility for their implementation assigned to relevant staff. Monitoring processes are required to provide follow though.

5. Feedback
Feedback (open disclosure) is offered to the patient and /or support person at the conclusion of a SAC 1 or SAC 2 investigation, in order to ensure feedback on the results of the investigation.

Feedback should also be given to the clinical staff and to relevant staff involved in the incident, including the patient’s treating doctor.

The Easy Guide to Incident Management provides further guidance.

Quality Review of Root Cause Analyses in HNE Health

In 2007 Clinical Governance introduced a monthly RCA Review Team (RCART) meetings to retrospectively review quality aspects of RCA reviews. Throught RCART, there have been improvements to the procedural aspects of RCA management and format and content of the final report, which have been commended by senior HNE Health staff. The meeting is chaired by the Director Clinical Governance and includes a senior Operations executive and Clinical Governance staff (Associate Directors; the patient Safety Manager and Patient Safety Officers who attend on a rotating basis). Each completed RCA is reviewed prior to the meeting according to agreed criteria, and the meeting then discusses key findngs and arranges post-meeting feedback to RCA Team Leaders about potential improvements.

The meeting also identifies Root Cause Analyses with potential outcomes and lessons for the whole of the Organisation, and these are featured in Quality Matters Clinical Governance's montly newsletter.

Monitoring and Evaluation Incident Management and Patient Safety Outcomes

The analysis of trends and patterns of incidents and adverse events facilitate system improvement. The outcome of the implementation of the Incident Information Management System (IIMS) has been successful in providing useful information that can be used to review incidents and adverse events, and to identify potential trends or areas for specific review or attention.

From this information NSW Health has developed a Lessons Learned web page. The monthly Quality Matters Newsletter published by HNE Health Clinical Governance also includes a monthly section on lessons learned from incidents and reviews.

In 2008, Clinical Governance implemented a quarterly reporting framework about incident management activity and outcomes. The following reports:

Patient Safety Officers

HNE Health Clinical Governance staff includes Patient Safety Officers who are attached to clinical units across HNE Health and based geographically close to their areas of responsibility. Their role is to work closely with their clinical colleagues and local managers in supporting local systems for incident management and review. Within Clinical Governance, the Patient Safety Officers also report to the Patient Safety Manager.

In order to identify the relevant local Patient Safety Officer for a specific service in HNE Health, please contact your local service/facility manager, or contact Ms Barbara Rodham, Patient Safety Manager, Clinical Governance on telephone (02) 4921 4168.

Open Disclosure

Open Disclosure is an important part of clinical communication and means that patients, families and those affected by an adverse event receive information about what happened, an apology, findings of an investigation of the event and what is being done to prevent recurrence.

Since 2007, Clinical Governance has supported HNE Health staff members to develop skills and practice open disclosure as part of routine clinical practice. Further information regarding HNE Health's procedures, experience and training is provided on the Open Disclosure pages on this site (Click Here).

Useful Links

Patient Safety, Incident Management and Open Disclosure

Quick Links