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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 (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, so that staff and managers can work together to improve the delivery of care for all patients. Some of these detailed analyses have been presented as Clinical Focus Reports which are developed in close collaboration with clinicians and are distributed widely in order to share the lessons learned.

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 enables any root causes, contributing factors and systems issues to be identified, and recommendations made to make health care services safer (Figure 1).

The Reportable Incident Brief (RIB) system is designed to report defined health care incidents to the NSW Ministry of Health. All SAC1 incidents, including national sentinel events, as outlined in the NSW Health Incident Management Policy PD2014_004, must be notified via the RIB process. National 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. There are eight (8) Nationally agreed sentinel events, these 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
The Clinical Excellence Commission (CEC) collates and analyses all clinical RIBs. The following report is informed by both the IIMS and the CEC RIB database.

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 to play 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 of incident data in the IIMS, including those focussed on the recognition and management of the deteriorating patient and addressing patients with sepsis.

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 work is part of the CEC's commitment to support the NSW health system in providing the safest and highest quality care for every patient.

For more information about the Clinical Excellence Commission, its programs, resources and publications see http://www.cec.health.nsw.gov.au


Included in this report

The information in this report includes data extracted from the IIMS, Riskman, Health Information Exchange (HIE) and the CEC RIB and RCA databases. For more specific extract information, please contact the CEC Patient Safety Team 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
    • 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. Further qualitative, rather than quantitative, interpretation of the data is therefore 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 PD2014_004. 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 score, the actual SAC score must be confirmed by a manager within five days of the incident notification. All SAC1 incidents, and National Sentinel Events require a Reportable Incident Brief (RIB) to be submitted to the NSW Ministry of Health.

Table 1: Clinical Incidents notified by Actual SAC rating, July 2012 - December 2016

Clinical Incident Management
Caveat:
*SAC1 data obtained from CEC RIB database, SAC2-4 obtained from IIMS/SVHN Riskman

There has been a five percent increase in the number of clinical incident notifications for July – December 2016. This increase is consistent when compared with previous reporting periods. The number of incidents reported in the months of July to December are consistently higher than incidents reported during the months of January to June.

Figure 2 and 3: Clinical SAC1 & SAC2 and SAC3 & SAC4 incident notifications, July 2012 to December 2016

Clinical Incident Management

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

Clinical Incidents per 1,000 Bed Days

Reporting the number of clinical incidents in relation to activity i.e. per 1,000 beds days, provides greater insight than the number of incidents alone. The rate of SAC1 and SAC2 incidents from 2012 - 2016 has remained stable.  SAC3 and SAC4 incidents that result in little or no harm have increased slightly during 2016.  This demonstrates NSW hospitals have a robust reporting culture and high reliability.  The rate of incidents per 1,000 acute bed days is consistent with previous incident reporting periods (Table 2).

Table 2: Clinical Incident notifications by SAC per 1,000 acute bed days, July 2012 – December 2016

Clinical Incident Management
Caveat:
*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 2012 to December 2016

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. Table 3 and Figure 6 display clinical incidents by PIT.

From July to December 2016, the top four PITs have remained consistent with previous reporting periods: Clinical Management, Fall and Medication/IV fluid and Pressure Ulcer (also known as Pressure Injury). Since January 2015, Clinical Management has replaced Falls as the most frequently reported PIT.

Reporting of pressure ulcers/ injuries demonstrates changes which could be due to the release of the Pressure Injury Prevention and Management policy PD2014_007, along with the National Safety and Quality Health Service Standards, the Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury (2012) , the International Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline (2014), and the establishment of a statewide working party in January 2013.

Table 3: Clinical Incidents by PIT as a percentage*, July 2012 - December 2016

Clinical Incident Management
Caveats:
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 blood/blood product, building/fitting/fixture/surround, complaint, 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 2012 - December 2016

Clinical Incident Management

SAC1 Reportable Incident Briefs (RIBs)

The total number of SAC1 notifications has increased for the July to December 2016 reporting period. The rate of SAC1 incidents has remained stable for a number of consecutive reporting periods.


The most frequently notified SAC1 incidents from July 2012 to December 2016 continue to be categorised under the PIT of Clinical Management. This includes incidents associated with diagnosis, patient identification, and treatment of patients in any inpatient care setting (Table 4).

Table 4: SAC1 incidents by PIT, July 2012 - December 2016

Clinical Incident Management
Caveats:
* 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 RCAs not reviewed, Medication/IV Fluid, Health care associated infection, RCAs not received, Medical Equipment/Devices and Undetermined cause of death
# Includes patient identification incidents

SAC2-4 IIMS Data


Table 5: SAC2 incidents by principal incident type, July 2012 - December 2016

Clinical Incident Management
Caveat:
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, Oxygen/gas/vapour, Pathology/laboratory and Security

Table 6: SAC3 incidents by principal incident type, July 2012 - December 2016

Clinical Incident Management
Caveat:
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 2012 - December 2016

Clinical Incident Management
Caveat:
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 NSW Health. The RCA method is used to identify how organisational systems can cause or contribute to clinical incidents. The investigation report findings, and statewide 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 and Clinical Focus Reports.

The CEC reviews all clinical RCA reports through four RCA review committees: Clinical Management; Maternal and Perinatal; Mental Health / Drug and Alcohol; and Child and Young Person. The RCA Review Committees classify each report using a standard taxonomy. The classification taxonomy is regularly adjusted in accordance to emerging issues and clinical practice changes.

During the reporting period of July to December 2016, the top two system factors identified by the RCA review committees were communication and care planning.

The system factor communication relates to both verbal and written forms of communication. This includes handover between clinicians or shifts, and clinical documentation and communication with patients, families and carers. Poor communication is also a common contributor to incidents in other industries. Human Factors is identified as a key element for improving communication and the CEC has developed Human Factors training which was launched in 2015.

The system factor care planning covers incidents where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team, including private providers, inpatient and community-based services. Care planning also covers incidents which arise when a patient's co-morbidities, falls risk, or the capacity of their carers to manage ongoing care have not been adequately assessed or addressed.

System Factors identified in the Clinical Management RCA Review Committee

The top three system factors identified by the Clinical Management RCA Review Committee (Table 8) were Care Planning, Communication, and Assessment.


Table 8 outlines the system factors identified in Clinical Management RCAs from January 2013 to December 2016 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 2013 - December 2016

Clinical Incident Management

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

Figure 7: Top three system factors identified through Clinical Management RCA reports, January 2013 - December 2016

Clinical Incident Management


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

A revised MHDA classification taxonomy was implemented in July 2016. It was developed with the assistance of mental health clinical experts, to ensure that the classification categories reflect current clinical care practices. This has been an iterative process with refinement to the classifications occurring over time.


The data from Mental Health / Drug and Alcohol RCAs has shown similar systems factors to clinical management RCAs. Table 9 outlines the system factors identified in Mental Health / Drug and Alcohol RCAs for the period January 2013 to December 2016, and figure 8 outlines the top three system factors identified through analysis of Mental Health / Drug and Alcohol RCAs for the period January 2013 to December 2016.

Table 9: System factors identified through review of Mental Health/Drug and Alcohol RCA reports, January 2013 - December 2016

Clinical Incident Management

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


Figure 8: Top three system factors identified through review of Mental Health/Drug and Alcohol RCA reports
January 2013 - December 2016

Clinical Incident Management

System Factors identified in the Maternal and Perinatal RCA Review Committee

In the July - December 2016 reporting period, Care Planning, Communication and Assessment were the most frequent system issues identified by the Maternity and Perinatal RCA committee.


Table 10 outlines the system factors identified in Maternal and Perinatal RCAs for the period January 2013 to December 2016 and Figure 9 outlines the top three system factors identified through Maternal and Perinatal RCAs for the period January 2013 to December 2016.


Table 10: System factors identified through Maternal and Perinatal RCA reports, January 2013 - December 2016

Clinical Incident Management

Figure 9: Top three system factors identified through Maternal and Perinatal RCA reports, January 2013 - December 2016

Clinical Incident Management

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

The Children and Young Person (CYP) RCA review committee was established in 2016. In the July 2016 to December 2016 reporting period, Care Planning, Assessment, Policy and Guidelines were the most frequent system issues identified (Table 11). With the evolution and maturity of the CYP RCA committee and the refinement of classification taxonomy, there has been an increased ability to gain greater system learnings. The increase in system factors in the July to December 2016 period can be attributed to these changes. Feedback reports in the form of Paediatric Watch Newsletters have been developed to share the learnings from incident notifications with clinicians across the state.

Table 11: System factors identified through Child and Young Person RCA reports, January 2015 - December 2016

Clinical Incident Management
Caveats:
* The system factor of Investigations was added as a system factor in July 2016
** In the July - December 2016 period, RCA reports involving Paediatric Mental Health were included
Risk Factors in RCA Reports

The clinical risk factors identified in the RCA review process relate to the conditions or situations that patients have been exposed to that were 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 associated RCA committees during the July - December 2016 reporting period.


Table 12: Top five risk factors identified through Clinical Management RCA reports, January 2013 - December 2016*

Clinical Incident Management
Caveat:
* Top five risk factors for July - December 2016

Table 13: Top five risk factors identified through Mental Health/Drug and Alcohol RCA reports,  January 2013 - December 2016*

Clinical Incident Management
Caveats:
* Top five risk factors for July - December 2016
** Definitions revised in 2016

*** New category collected from July - December 2016

Through close collaboration with mental health and drug and alcohol clinical experts, the MHDA classification taxonomy has been strengthened. The MHDA risk factors (Table 13) are reflective of these changes. In previous reporting periods there was a clinical risk group 'deteriorating MH status'. This has devolved into 'deteriorating MH-failure to recognise' and 'deteriorating MH-failure to escalate' with the latter commencing collection in July 2016. The clinical risk factors 'shared care - GP' and 'therapeutic relationship not achieved/sustained' have been clinical risk factors that have been collected over multiple reporting periods, but the definitions from July 2016 have been refined. These stronger definitions are reflected in the change in reporting trend for these two risk factors. 'Risk Assessment Mental Health' is a new category since July 2016.

Table 14: Top five risk factors identified through Maternal and Perinatal RCA reports, January 2013 - December 2016*

Clinical Incident Management
Caveat:
* Top five risk factors for July - December 2016

Table 15: Top five risk factors identified through Child and Young Person RCA reports, January 2015 - December 2016*

Clinical Incident Management
Caveats:
* Top five risk factors for July - December 2016

**In the July - December 2016 period RCAs involving Paediatric Mental Health are now included

The recognition of response to, and management of, deterioration is a risk factor identified by all RCA committees. To address the problems associated with failure to recognise, escalate and respond to patient deterioration, the CEC's Between the Flags program provides a suite of standard observation charts which incorporate standard calling criteria to escalate care of the patient. 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 matching of the correct patient, site and procedure. The NSW Health Policy – Clinical Procedure Safety (PD2014_036) describes the steps that must be taken to ensure that an intended invasive or diagnostic procedure (including surgical operations, endoscopy, dentistry, radiology, nuclear medicine, chemotherapy and radiation therapy) is performed on the correct patient, at the correct site and, if applicable, with the correct implants/prostheses and equipment.

Prior to 10 February 2014, all incidents which involved the incorrect patient, procedure, body part or surgical implant were classified as serious incidents (SAC1) in the Incident Information Management System (IIMS) and subsequently underwent RCA investigation. In 2014, the NSW Health Incident Management Policy (PD2014_004) was amended and mandated that incorrect patient, site, and/or procedure incidents be classified according to actual harm, and those not resulting in harm are no longer automatically recorded as a SAC1 incident.

Procedures involving the wrong patient or body part, regardless of the outcome, requires notification to the Ministry of Health as a Reportable Incident Brief (RIB). These incidents are referred to as patient identification incidents in this report.

From July to December 2016, there were two SAC1 incidents in the Operating Theatre / Anaesthetics. There has been an eighteen per cent (18%) decrease in SAC2-4 notifications when compared with the previous reporting period. These incidents involve mismatching / failure to correctly identify patients prior to intended clinical intervention which may include diagnostic imaging and pathology tests. In most cases, these events have not resulted in actual harm to the patient.

Table 16: Location of SAC1 incidents involving patient identification where clinical procedure has occurred
July 2012 - December 2016
Clinical Incident Management
Caveats:
* Incorrect patient / procedure / site reporting requirements changed 10 February 2014
** Incidents already accounted for in SAC1 data as displayed in Table 4

Table 17: Location of SAC2, SAC3 and SAC4 incidents involving patient identification where clinical procedure has occurred
January 2014 - December 2016

Clinical Incident Management

Caveat:
* 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 and increased use of resources. Hospitalised patients older than 75 years of age have a significantly higher risk of falling (Figure 10). They often exhibit frailty, poor mobility, and confusion. The confusion can be caused by dementia and or delirium, an unfamiliar hospital environment, acute illness and 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.

Figure 10: Falls by age, January 2013 - December 2016

Clinical Incident Management

The Severity of Inpatient Fall


During the reporting period July - December 2016, the number of incidents with a principal incident type of fall was 13,606. Of these incidents, 24 were classified as SAC1 and 248 were classified as SAC2 incidents. The SAC1 and SAC2 incidents account for 2 per cent of all falls notified. It is important to note that the majority of fall events were categorised as a SAC3 or SAC4 events which did not result in serious patient harm.


Table 18: Falls by SAC rating, July 2012 - December 2016

Clinical Incident Management
Caveat:
* 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 2012 - December 2016

Clinical Incident ManagementCaveat:
* 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 2016 reporting period was loss of balance and slips (Figure 13). Of those, forty-two per cent (42%) of patients reported as moving and twenty-one per cent (21%) were standing when the fall occurred (Figure 14). A further fourteen per cent (14%) of patients were undertaking activities of daily living, such as unassisted toileting and showering. This is consistent with the data in previous reporting periods.


Figure 13: Type of fall, July 2012 - December 2016

Clinical Incident Management

Figure 14: Activity at time of fall, July 2012 - December 2016

Clinical Incident Management

Time of Patient Falls

Falls occur most frequently between 0900 and 1159hrs. During these times, patients are more likely to be up and mobilising, attending to personal care. Significant activity occurs on wards during these times with clinical handover, ward / medication rounds and diagnostic testing. Other peak times for falls are 1300 - 1459hrs and 1800 - 1859hrs which coincides with increased patient activity and toileting following meal times.


Figure 15: Time of patient falls, January 2013 - December 2016

Clinical Incident Management

Outcomes Following a Fall

Of the fall incidents reported during the July - December 2016 reporting period, forty-nine per cent (49%) of falls resulted in no harm to the patient. Twenty-six per cent (26%) resulted in an injury to the patient. These injuries often require intervention. There were fourteen (14) fall incidents (0.11%) recording death as an outcome for this period.

Table 19: Outcome of fall, July 2012 - December 2016

Clinical Incident Management
Caveat:
* Multiple responses are allowed in the 'outcome' field and is not mandatory for completion
Clinical Incident Management


Medication Related Incidents


The prescription and administration of medication is the most common intervention in the NSW health system. During the reporting period July - December 2016, medication incidents were the third most commonly reported clinical incident. It is important to note that 99.5 per cent of these incidents resulted in either little or no harm to patients. The information notified in the 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 2016, less than half of one per cent (0.33%) of medication incidents notified were rated as SAC1 or SAC2 incidents. Sixty-five per cent of all medication incidents received the lowest severity rating (SAC4), a further thirty-two per cent were identified as SAC3, and the remaining 3 per cent 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 2012 - December 2016

Clinical Incident Management
Caveats:
* SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from NSW IIMS

** Includes St Vincent's Health Network data January - December 2013

Figure 16 and 17: Medication incidents by SAC1 & SAC2 and SAC3 & SAC4 rating, July 2012 - December 2016

Clinical Incident Management
Caveat:
* 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 2012 - December 2016

Clinical Incident Management
Caveats:
* SAC1 data obtained from CEC RIB database, SAC2-4 data obtained from NSW IIMS

** Includes St Vincent's Health Network data January - December 2013


Type of Medication Incident

During the reporting period July - December 2016, there were 13,687 medication-related notifications (Table 20). Medication administration incidents continue to be the most frequently reported since 2012, 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. Table 22 outlines the medication incidents by type and reporting period.

Forty-one per cent (41%) of medication-related incidents include medications being administered incorrectly, for example oral instead of intravenous, in the wrong amount, or at the wrong time. Twenty per cent (20%) were prescribing errors which includes illegible writing, incomplete prescriptions or errors made on the prescription (Table 22).

Table 22: Medication incidents by type, July 2012 - December 2016

Clinical Incident Management

Caveats:
* Multiple responses are allowed in the 'medication problem type' field and is not mandatory for completion
**Includes St Vincent's Health Network data January - December 2013
*** 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 incidents during the reporting period July - December 2016 included opioids (such as oxycodone, morphine, fentanyl, hydromorphone and methadone) insulin and anticoagulant medicines (such as enoxaparin, heparin and warfarin) (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, January 2013 - December 2016

Clinical Incident Management
Caveats:
* Multiple responses are allowed in the 'medication involved' field and is not mandatory for completion
**Includes St Vincent's Health Network data January - December 2013
*** Includes Oxycodone and Oxycodone Hydrochloride
**** Includes Morphine and Morphine Sulfate

Time of Medication Incident


During the reporting period July - December 2016, the peak time for medication related incidents was between 0800-0859hrs, when fifteen per cent (15%) of incidents occurred, and between 2000-2059hrs when a further nine per cent (9%) 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, January 2013 - December 2016

Clinical Incident Management

The Outcome of Medication Incidents


During the reporting period July - December 2016, fifty-two per cent (52%) of medication related incidents did not result in patient harm. Twenty-four per cent (24%) of incidents, the outcome was unknown or unspecified. Less than six per cent (6%) of incidents resulted in pathophysiological factor, procedural complication or patient injury (Table 24).


Table 24: Outcome of Medication Incidents, January 2014 - December 2016

Clinical Incident Management
Caveat:
* Multiple responses are allowed in the 'outcome' field and is not mandatory for completion

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 a reliable indicator of safer care. Further qualitative, rather than quantitative, interpretation of the data is therefore recommended.


Paediatric Quality Care in NSW


The Paediatric Quality Program works across a range of areas to improve the quality and safety of health care for children and young people in NSW.

This program is the centralised point of information for paediatric quality and safety for clinicians in NSW Health.

The Program contributes to the development of the paediatric components for selected CEC programs, including Sepsis Kills, Between The Flags and the Falls Prevention programs.

The number of reported incidents has increased in July – December 2016, as compared with the January – June 2016 reporting period. Table 25 outlines the final SAC allocation for all incidents involving patients aged between 0 and 16 years of age.


Table 25: Clinical incidents 0-16 years by SAC rating, July 2012 - December 2016

Clinical Incident Management
Caveat:
* 2016 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

Figure 19 and 20: Clinical incidents 0-16 years by SAC1 & SAC2 and SAC3 & SAC4, July 2012 - December 2016

Clinical Incident Management
Caveat:
* 2016 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 2012 – December 2016

Clinical Incident Management


Clinical management continues to be the most prevalent PIT among paediatric-related incidents and includes incidents associated with diagnosis and treatment. Paediatric clinical leads across NSW have prioritised the recognition and treatment of paediatric sepsis as a patient safety priority. Implementation of the Paediatric Sepsis Pathway promotes the involvement of a senior clinician to support early decision making and administration of life-saving antibiotics and intravenous fluids.


Medication / IV fluid continues to be the second most prevalent PIT (Figure 22) and includes incidents associated with administration, prescribing, dispensing, drug count discrepancies, delivery issues, and storage of medication / IV fluids.

Figure 22: Clinical incidents 0-16 years by top four principal incident types (PIT), July 2012 – December 2016

Clinical Incident Management

At a state level, the CEC has established the Children and Young Person (CYP) RCA Review Committee to provide specialty focussed classification of RCA reports involving paediatric patients. Further information regarding the outcomes of this committee can be viewed on the RCA tab of this report.


The CEC Paediatric Safety & Quality Program has recently distributed eight safety information newsletters related to paediatric safety entitled Paediatric Watch - Lessons from the frontline. These newsletters provide frontline clinical staff with feedback and information on key system issues so they can learn about providing safe and reliable practice.


National Sentinel Event (NSE)


In 2002, Australian states and territories agreed to the ongoing contribution to a set of eight national core sentinel events, which have been reported nationally since 2004. 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 (8) 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 therefore caution is required in interpreting these data.

Commencing in 2007, sentinel events reported by each Australian jurisdiction have been included in the Productivity Commission’s Report on Government Services (RoGS). These data are published each January in the annual Report on Government Services (RoGS).

Suicide of a patient in an inpatient unit

There has been a decrease of twenty per cent (20%) in inpatient suicides, from eighteen (18%) in 2013-14, to fifteen (15%) in 2014-15. It is important to note that the definition of events in this category are aligned with the Australian Commission for Safety and Quality in Healthcare (ACSQHC) definition which includes patients on approved leave and those absconding from care.

Retained material

There has been an increase of ten per cent (10%) in retained instruments or other material requiring re-operation or further surgical procedure. Eight out of twenty of these events occurred in private health facilities.

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 focussed 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 2014-15 period, there has been a decrease (76%) of medication errors resulting in death due to incorrect administration of drugs, which may be attributed to NSW public hospitals’ uptake of the improvement strategies and resources.

Maternal deaths

There has been an increase in the number of maternal deaths associated with pregnancy, birth or the puerperium in the 2014-15 reporting period. However, the definition was altered for the 2014-15 reporting period to include both the antenatal and post natal periods, whereas the previous definition included delivery only. Subsequently, the 2014-15 number is not comparable to any results previously published.

During 2016-2017, the Australian Commission for Safety and Quality in Health Care (ACSQHC) facilitated a review of the existing sentinel events, in consultation with clinicians and healthcare consumers. Finalisation of the revised list of sentinel events is expected to occur during the second half of 2017.

Table 26: NSW selected sentinel events (*)

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Caveat:
* Sentinel events definitions can vary across jurisdictions.
National Sentinel Event data for 2015-16 will be provided early 2018.
(b) 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 not comparable to results published in the 2014 Report and prior versions.
Source: Report on Government Services 2017, Chapter 12, Volume E available at
http://www.pc.gov.au/research/ongoing/report-on-government-services/2017/health/public-hospitals/rogs-2017-volumee-chapter12.pdf

Table 27: Australian Total selected sentinel events (*)

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Caveat:
* Sentinel events definitions can vary across jurisdictions.
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 2015-16 will be provided early 2018.
Source: Report on Government Services 2017, Chapter 12, Volume E available at

http://www.pc.gov.au/research/ongoing/report-on-government-services/2017/health/public-hospitals/rogs-2017-volumee-chapter12.pdf


Complaints and their resolution

A priority of the NSW public health system is its focus on patient-centred care. Feedback from consumers of health care services, their families and carers 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 has seen a slight decrease of 0.54 per cent over the reporting period of July - December 2016.

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

Figure 23: Notification of clinical incidents and complaints by NSW separations, July 2012 - December 2016

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Table 28: Complaints by SAC rating, July 2012 - December 2016

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Caveat:
* 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 2016 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 2012 - December 2016

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Caveat:
* 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 2012 - December 2016

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The nature of complaints


The nature of the complaint is a further analysis of the complaint issue type identified from the consumer's perspective. Treatment, communication and access to discharge transport continue to be the most reported complaint categories since July 2012.

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. Inadequate treatment was more than double that of the next highest nature of complaint about treatment (Table 30).


Table 30: Nature of complaint about treatment, July 2012 - December 2016

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Caveat:
* 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 2012 - December 2016

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Caveat:
* 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 and services availability, and waiting lists. Access complaints highlight consumers’ concerns about demands on the health care system (Table 32).


Table 32: Nature of complaint about access, July 2012 - December 2016

Clinical Incident Management
Caveat:
* This is not a mandatory field and multiple responses are allowed

Resolution of complaints


The top five most common forms of complaint resolution remains consistent with previous reporting periods and includes: 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 2012 - December 2016

Clinical Incident ManagementCaveat:
* 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 2012 - December 2016

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How the complaint was received

During the July - December 2016 reporting period, complaints were most commonly communicated directly by telephone (35%), by letter / email (21%), and in person (19%). A small number were received via other entities, including the Health Care Complaints Commission (8%), NSW Minister and Members of Parliament (6%), Local Health Districts (2%). NSW Ministry of Health, Official visitors, NSW Ombudsman, Other State Government, Commonwealth Government Department, Health Insurance Commission, NSW State Coroner and 'Other' made up the remainder (9%).


Table 34: How the complaint was received, January 2014 - December 2016

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Caveat:
* 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 complainants perspective e.g. the issue was communication and the nature was the attitude of staff. A list is available within the IIMS 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

Is a series of focussed summary reports based predominantly on incidents which have been subjected to root cause analysis or other investigative methodologies. The aim is to provide 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) which may require patients to undergo a further procedure to remove the retained item.


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.


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.

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

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; and 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 a staff member behaving in a rude or hostile manner.


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 ml/hour instead of 40 ml/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 when it should have been 8L/min, 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 ulcers or the worsening of pre-existing pressure ulcers which occur during clinical care. An example is when a bed-bound patient develops a pressure area.


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.

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