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The Clinical Excellence Commission The eChartbook


Incident Management System CEC Indicators Incident Information Management System (IIMS)
Clinical incident notifications: Strengthening the learning and reporting culture in healthcare
For more information about this CEC program, click here
 


Why is this important?


The Incident Information Management System (IIMS) was established in 2005, as a key component of the NSW Patient Safety and Clinical Quality Program. Gathering information on all incidents that might affect patient safety, whether or not harm occurred, enables contributory factors to be analysed and system-wide lessons learned. All NSW Health staff are responsible for notifying all incidents, near-misses and complaints, using IIMS.


Each incident notified in IIMS requires an investigation, in accordance with the level of risk it presents. The Severity Assessment Code (SAC) is used to rate incidents by assessing the consequences and the likelihood of re-occurrence. Of the four ratings, SAC1 is the most serious:

  • Clinical SAC1 incidents must be reported to the Ministry of Health within 24 hours and are investigated using root cause analysis (RCA). This category includes the unexpected death of any patient, suspected suicide of mental health patients and procedures involving the wrong patient or body part
  • SAC2 incidents require investigation at the local health district (LHD) level
  • SAC3 and SAC4 require local action, including assigning management responsibility.

St Vincent's Health Network applies the same approach, but uses a different incident management system. Their clinical incident data is now included in the following chart and table. LHDs are responsible for ensuring monitoring and risk rating of all incidents. The Clinical Excellence Commission (CEC)is responsible for reviewing trends in incidents and providing information on clinical risks. The NSW Ministry of Health and the CEC have systems in place to disseminate lessons learned from incident management and to report their findings broadly. During 2011 there were over 15,000 notifications per month (up to 16,245), of which up to 13,000 were clinical incidents. (Total incidents -181,000, total clinical incidents - 134,000).


Findings


The overwhelming majority of IIMS clinical notifications (95%) are in categories SAC3 and SAC4, where there has been minimal, or no harm, to the patient, but where staff have identified risk. In 2011, SAC1 incidents comprised half of one per cent of clinical incident notifications, as shown below. Analysis of incident data occurs at State level in a number of ways and the findings are used to drive improvements in clinical care systems across NSW. The table below and further information about incidents and actions taken in response to them, can be found in the Incident Management reporting series and on the CEC Patient Safety Program web page.


There is substantial variation in IIMS reporting rates. High-reliability organisations (those with the best safety records) recognise the importance of no-blame incident reporting systems as a method of learning about the types of errors which may occur. This enables systems to be put in place to reduce the risk of these errors recurring (Reason, 2000). In health, a high rate of reporting is a positive situation and may suggest that staff are more vigilant in identifying anything that may constitute a risk to patient safety. The relative rate allows us to monitor variation in the proportion of the component SAC ratings.



Table IM01 - Clinical incident notifications and episodes of inpatient care, July - December 2011
SACRatingNumberSAC ratings as a percentage of notificationsPercentage of separations about which an incident was reportedClinical incidents per 1,000 bed days
SAC 1 309 0.44 0.04 0.01
SAC 2 1,384 1.95 0.16 0.4
SAC 3 30,688 43.2 3.63 9.2
SAC 4 34,775 48.96 4.11 10.5
No SAC allocated 3,874 5.45 0.46 1.2
Total 71,030 100 8.39 21.4

Table IM02 - Clinical incident notifications and episodes of inpatient care, January - June 2011
SACRatingNumberSAC ratings as a percentage of notificationsPercentage of separations about which an incident was reportedClinical incidents per 1,000 bed days
SAC 1 269 0.4 0.03 0.1
SAC 2 1,261 1.9 0.16 0.4
SAC 3 29,059 43.7 3.6 9.1
SAC 4 32,869 49.43 4.07 10.3
No SAC allocated 3,034 4.56 0.38 0.9
Total 66,492 100 8.24 20.8

Source: NSW Ministry of Health, Clinical Excellence Commission

Note: The NSW total included all clinical incidents notified by St Vincent's Health Network.


Implications


The analysis of clinical incident data trends and contributing factors provides the opportunity to improve the management in the environment where they occurred. This information also informs Statewide programs such as Falls Prevention, Medication Safety and Sepsis Kills, which were initiated following detailed analysis of IIMS and RCA reports.


What we don't know


It is inappropriate to attribute any direct relationship between the numbers of incidents reported and the safety and quality of clinical care. It is the content of notifications, not the count, which informs the system about where improvements need to occur. Fostering a reporting culture where staff speak-up about issues which they may previously not have regarded as incidents, is vital for patient safety.


Chart IM01 - IIMS notifications by SAC classification
 

Percentage distribution of IIMS notifications by SAC classification and local health district of treatment, 2007-2011

eChartbook

Source: NSW Ministry of Health, Clinical Excellence Commission

NSW 2011 data included all clinical incidents notified by St Vincent's Health Network).


End Matter


Contributors

Drafted by: CEC Patient Safety team


Data analysis by: CEC eChartbook team

Reviewed by: CEC Patient Safety team
Edited by: CEC eChartbook team


Suggested citation

Clinical Excellence Commission [access date]. eChartbook Portal: Safety and Quality of Healthcare in New South Wales. Sydney: Clinical Excellence Commission. Available at: http://www.cec.health.nsw.gov.au/echartbook/cec-indicators-intro-echartbook/cec-indicators-iims-chartbook Accessed [insert date of access].


© Clinical Excellence Commission 2013

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Clinical Excellence Commission (CEC). Requests and enquiries concerning reproduction and rights should be directed to the Director, Corporate Services, Locked Bag 8, Haymarket 1240.


Evidence-base for this initiative



Reported elsewhere

CEC IIMS Report - http://www.cec.health.nsw.gov.au/knowledge-and-resources/publications-library/reports


Definitions


Chart: IM01

Admin Status: Current

Indicator Name: Clinical incident notifications per 100 separations

Description: Rate of IIMS notifications by SAC classification per 100 separations by local health district of treatment, 2007-2011

Dimension: Performance of health service provider: reporting culture in health care

Clinical Area: Initiatives in safety and quality

Numerator: Total number of IIMS notifications and SVHN clinical incident (for 2011) by SAC classification (SAC1, SAC2, SAC3, SAC4)

Denominator: Total number of separations by SAC classification (SAC1, SAC2, SAC3, SAC4)

Data Exclusions: None

Data Inclusions: All IIMS and St Vincent's Health Network (SVHN) clinical incident notifications included

Standardisation: None (crude rate per 100 was calculated)

Data Source: Incident Information Management System (IIMS), Clinical Excellence Commission and NSW Ministry of Health, SVHN Clinical Governance Unit

Comments: Not Applicable