Biannual Incident Report (January – June 2020)

From 14 December 2020 serious incident management in NSW has changed. This report refers to incident management processes in place prior to 14 December 2020. Click here for information about the changes to incident management in NSW.

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

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 them from happening again. This is supported by NSW Health Incident Management Policy PD2020_047.

The incident reporting system in the NSW public health system is the Incident Information Management System (IIMS). The IIMS has been used to notify and manage incidents since 2005. From October 2019, NSW Health commenced a staged introduction of a new system, ims+, to report and manage incidents, hazards, and near misses. Local Health Districts and Specialty Health Networks have begun transitioning onto the new ims+ system. It is expected that all Local Health Districts and Specialty Health Networks will be using the system by December 2020. The St Vincent's Health Network (SVHN) uses Riskman as their incident reporting system and will continue to do so.

Analysing incidents allows the health system to identify significant issues, risks, and trends relating to health care and put supports in place to help prevent future incidents from occurring.

Incidents reported in IIMS are risk rated against a Severity Assessment Code (SAC), while incidents reported in ims+ are rated against a Harm Score. The key purpose of the SAC/Harm Score is to direct the level of investigation and action required for a particular incident. There are four SAC/Harm Score ratings, ranging from SAC/Harm Score1 (extreme risk) to SAC/Harm Score4 (low risk). The Harm Score in ims+ is based on the outcome for the patient and any additional care required as a result of the incident.

As outlined in the NSW Health Incident Management Policy, all SAC/Harm Score1 incidents are required to undergo a thorough investigation known as a Root Cause Analysis (RCA). This investigation method identifies root causes, contributing factors, and/or systems issues which may have contributed to the incident. Recommendations are made by RCA investigation teams to reduce the risks identified. The recommendations of the RCA investigation are tracked by the relevant Local Health District, and the lessons are shared with the broader health system when warranted.

Part of the investigation process involves notifying the appropriate people and organisations, investigating the incident, and completing Open Disclosure with patients, family members, and staff involved. (Figure 1 provides the framework for the investigation process used during the January – June 2020 reporting period.)

The NSW Ministry of Health is notified of SAC/Harm Score1 incidents, including National and Australian Sentinel Events (NSE / ASE), and other significant clinical incidents. This is done in accordance with the NSW Health Incident Management Policy, through a Reportable Incident Brief (RIB).

Sentinel Events are a rare group of incidents that are wholly preventable and result in serious harm to, or the death of, a patient. The eight national Sentinel Events which have been reported nationally since 2004 (up to June 2019, and included within this report) include:

1. Procedures involving the wrong patient or body part resulting in death or major permanent loss of function;
2. Suicide of a patient in an inpatient unit;
3. Retained instruments or other material after surgery requiring re-operation or further surgical procedure;
4. Intravascular gas embolism resulting in death or neurological damage;
5. Haemolytic blood transfusion reaction resulting from ABO incompatibility;
6. Medication error leading to the death of a patient reasonably believed to be due to the incorrect administration of drugs;
7. Maternal death associated with pregnancy, birth and the puerperium; and
8. Infant discharged to the wrong family.

In December 2018, a revised Australian Sentinel Events (ASE) list was agreed by Australian Health Ministers in December 2018 and came into effect on 1 July 2019. The revised list of Australian Sentinel Events (ASE) increased from eight events to ten. For more information, please see the Australian Commission on Safety and Quality in Health Care website.

Maternal death associated with pregnancy, birth and the puerperium, and intravascular gas embolism resulting in death or neurological damage, were removed from the ASE list.

The Clinical Excellence Commission (CEC) reviews all clinical RIBs reported in NSW and analyses the data to determine focus areas for improvement. This report is informed by the IIMS, ims+, RIB, and RCA data.

During the reporting period, more health services commenced use of ims+. Due to the differences between the IIMS and ims+ systems with regards to the classification of clinical incidents and complaints, data displayed within this report is combined to include ims+ at a high level.

The CEC's role in Incident Reporting

The CEC is the lead agency supporting patient safety and clinical quality improvement in the NSW public health system and has a key role in analysing and reporting on the information found in IIMS and ims+. The CEC has developed a number of projects and programs which have resulted from the analysis of incident data in the IIMS. These programs include those focused on the recognition and management of deteriorating patients (Between the Flags) and addressing patients with sepsis (SEPSIS KILLS).

The CEC continues to work with health services to strengthen the management of incidents across NSW Health.

NSW Health was the first Australian jurisdiction to publicly report healthcare incident data. The first report was released in 2005. The CEC published its first web-based clinical incident management report in 2013. This regular publication of data is part of the CEC's commitment to be transparent, accountable, and supportive of NSW Health clinicians and teams to provide the safest and highest quality care for every patient, every time.

For more information about the CEC, its programs, resources and publications see the CEC website.

Included in this report

The information in this report includes data from the IIMS, ims+, the RIBs, RCAs, Riskman and Health Information Exchange (HIE). For more specific extract information, please contact the CEC Patient Safety Team via via email.

This report contains:

• An explanation of 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
• National Sentinel Events; and
• Complaints notified in IIMS and ims+.

Data interpretation

Analysis of the information contained within the IIMS and ims+ may provide greater insight into how incidents occur, provide context, highlight issues, and identify system-related opportunities for improvement.

Given the wide variation between services and facilities, it is difficult to make accurate comparisons based on notification numbers alone. Caution is advised if using IIMS and ims+ 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, therefore further qualitative, rather than quantitative, interpretation of the data is recommended.