Biannual Incident Report

January – June 2021

An incident is an unplanned event that results in, or has the potential for, injury, damage or loss, including near misses. An incident may also be referred to as an 'adverse event'.¹

NSW Health is committed to learning from incidents and requires all staff to report patient-related incidents (also referred to as clinical incidents), corporate incidents, near misses, and consumer feedback so that risks to patient safety are recognised and action can be taken to reduce the risk of them happening again. This commitment to patient safety is consistent with the NSW Health Incident Management Policy Directive PD2020_047.

Since 2005, NSW Health facilities have used an electronic Incident Information Management System (IIMS) to notify and manage incidents as they occur. In October 2019, NSW Health started the transition to a new system, ims+, to report and manage incidents, hazards, consumer feedback and near misses. ims+ was in use across all public health services by 31 December 2020. St Vincent's Health Network (SVHN) uses the Riskman incident reporting system.

Patient related incidents reported in ims+ are risk rated against a Harm Score, which is based on the severity of the outcome for the patient and any additional care required due to the incident. The Harm Score directs the level of review and action required for a particular incident. There are four Harm Score ratings, ranging from Harm Score 1 (serious harm) to Harm Score 4 (no harm or near miss).

As outlined in the NSW Health Incident Management Policy, clinical Harm Score 1 incidents must undergo a thorough review known as a Serious Adverse Event Review (SAER). The approved review methodologies seek to identify factors that caused or contributed to an incident and/or systems issues. Recommendations are made by SAER teams to reduce the risks identified and these are tracked by the relevant Local Health Districts (LHD) or Specialty Health Networks (SHN). Lessons are then shared with the broader health system where relevant.

The review process involves notifying the appropriate people and organisations reviewing the incident, and engaging with patients and families in the open disclosure process. Figure 1 provides the framework for the review process during the January – June 2021 reporting period.

The NSW Ministry of Health (MoH) is notified of Harm Score 1 incidents, including National/Australian Sentinel Events (NSE/ASE), and other significant clinical incidents through a Reportable Incident Brief (RIB).

Sentinel Events are rare incidents that are considered to be wholly preventable and have caused serious harm to, or the death of, a patient. Eight NSEs have been reported nationally between 2004 to June 2019. The NSE list was revised and endorsed by Australian Health Ministers in December 2018. The revised list now referred to as ASEs commenced on 1 July 2019 and increased to ten Sentinel Events.

For more information on Sentinel Events, please see the Australian Commission on Safety and Quality in Health Care website.

The CEC's role in Incident Reporting

The Clinical Excellence Commission (CEC) is the lead agency supporting patient safety and clinical quality improvement in the NSW public health system and has a key role in reviewing all clinical incident reported in NSW. The CEC analyses incident data to determine focus areas for improvement.

The CEC has developed a number of quality improvement projects and programs in response to the analysis of statewide incident data. These programs include those focused on the recognition and management of the deteriorating patient and addressing patients with sepsis.

NSW Health was the first Australian jurisdiction to publicly report healthcare incident data in 2005. The CEC published its first web-based clinical incident management report in 2013. The regular publication of this report is part of the CEC's commitment to be transparent, accountable and supportive of NSW Health clinicians and staff 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.

In this report

The information contained within this report includes data from ims+, RIBs, SAERs, Riskman and the Health Information Exchange (HIE). For more specific extract information, please contact the CEC Patient Safety Directorate via email CEC-patientsafety@health.nsw.gov.au.

As at January 2021, all NSW public health services had transitioned across to the ims+ application. This report contains an analysis of patient related incidents and consumer feedback reports recorded within ims+. The CEC have taken this opportunity to redevelop the format of this report and leverage reporting of ims+ specific datasets.

The January – June 2021 report provides a starting point for the future reporting of incident data across NSW. A number of changes have been implemented within this report, including the way data has been extracted and presented. It is important to note data contained within this report cannot be compared to data provided in previous reports. The report relating to the period 1 January 2017 to 31 December 2020 can be found here.

This report contains:

• An explanation of how to interpret the data presented
• Patient related incident data
• Patient related RIB data
• Systems and risks factors in serious clinical incidents identified through serious adverse event reviews (SAER)
• Sentinel Events
• Consumer Feedback including complaints and compliments.

Data considerations

Analysis of the information contained within the incident management system 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. Many variables can influence incident reporting. Incident reporting counts or rates should not be used as the single source of benchmarking data for a project or program.

Lower rates of reporting are not a reliable indicator of safer care, therefore, further qualitative, rather than quantitative, interpretation of the data is recommended. These data are not an epidemiologic data set, and no conclusions should be drawn about the relative frequency of events or trends in events over time.

References

¹Organisation for Economic Co-operation (OECD) (2017).