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 oriented towards 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 prioritised and 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 within a culture of trust and mutual respect.
The NSW Health Incident Management Policy PD2019_34 (Replaces PD2014_004) provides more details on how incidents are managed in NSW Health facilities.
|NSW Health employees can submit patient safety incidents here|
Incident Investigation Resources
Templates for conducting a root cause analysis are available here. The following incident investigation resources are available for Falls