Biannual Incident Report (July – December 2019)

From 14 December 2020 serious incident management in NSW is changing. 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.

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 PD2020_047.

The incident reporting system in the NSW public health system is called the Incident Information Management System (IIMS). Commencing in October 2019, NSW Health introduced a new system to capture and manage incidents, hazards and near-misses, known as ims+. St Vincent's Health Network (SVHN) 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. This facilitates improvement work, ultimately improving the reliability and safety of clinical care being provided to patients. Dissemination of the lessons learned to staff is through regular reports on key findings, in-depth analysis of clinical issues, and focused summary reports.

ims+ is progressively being rolled out statewide, with all health services transitioning across to the new application by the end of 2020.

Incidents reported in the IIMS 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 identifies root causes, contributing factors and/or systems issues, and recommendations are made to mitigate the risks identified.

Following the identification of a SAC1 incident there is a defined process which takes place, from point of notification and investigation, to open disclosure and analysis of findings, and dissemination of lessons learned. (Figure 1).

The NSW Ministry of Health (MoH) is notified of SAC1 and other significant clinical events through the Reportable Incident Brief (RIB) system. All SAC1 incidents, including National Sentinel Events (NSE), as outlined in the NSW Health Incident Management Policy PD2020_047 must be notified via the RIB process. 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. During July - December 2019 there were eight nationally agreed sentinel events, these were:

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 incorrect administration of drugs
7. Maternal death associated with pregnancy, birth and the puerperium
8. Infant discharged to the wrong family.

A revised Australian Sentinel Events (ASE) list was endorsed by Australian Health Ministers in December 2018. NSW Health will require the revised ASEs to be notified, via the Reportable Incident Brief System, from 1 July 2019 and investigated accordingly. The revised ASE definitions now increase the number of NSEs from eight to ten. Maternal death or serious morbidity associated with labour and delivery, and intravascular gas embolism resulting in death or neurological damage have been removed.

The Australian Sentinel Event list (version 2) 2018 includes;

1. Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
2. Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death
3. Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death
4. Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
5. Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
6. Suspected suicide of a patient in an acute psychiatric unit or acute psychiatric ward
7. Medication error resulting in serious harm or death
8. Use of physical or mechanical restraint resulting in serious harm or death (New)
9. Discharge or release of an infant or child to an unauthorised person
10. Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death (New).

The Clinical Excellence Commission (CEC) collates and analyses all clinical RIBs. The following report is informed by the IIMS, ims+, CEC RIB and RCA databases.

Due to the differences that exist between the IIMS and ims+ systems with regards to the classification of clinical and complaints, data displayed within this report include ims+ at a high level.

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 in analysing and reporting on the information provided from the IIMS and ims+. The CEC has developed a number of projects and programs which have resulted from the analysis incident data in the IIMS, including those focused on the recognition and management of the deteriorating patient (Between the Flags) and addressing patients with sepsis (SEPSIS KILLS).

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. This regular publication of data is part of the CEC's commitment to be transparent and support the NSW health system in providing the safest and highest quality care for every patient.

Included in this report

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

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
  • Neonatal/Paediatrics
  • National Sentinel Events
• Complaints notified in the incident information management system and how they are resolved.

Data Interpretation

The IIMS and ims+ 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 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.