Biannual Incident Report (July – December 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, including near misses. An incident may also be referred to as an 'adverse event'.¹

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 the NSW Health Incident Management Policy PD2020_047.

The Incident Information Management System (IIMS) has been used across the NSW public health system 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 (LHDs) and Specialty Health Networks (SHNs) have progressively transitioned onto the new ims+ application, with all health services transitioning across to the new application by the end of 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, risk and trends relating to health care and to put systems in place to help prevent future incidents from occurring.

The risk of clinical incidents reported in IIMS is rated using a Severity Assessment Code (SAC), while incidents reported in ims+ use a Harm Score (HS). 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 Score 1 (extreme risk) to SAC/Harm Score 4 (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 Score 1 incidents are required to undergo a thorough investigation known as a Serious Adverse Event Review (SAER). The SAER investigation process aims to identify the causes and factors which may have contributed to the incident. Recommendations are made by SAER investigation teams to reduce the risks identified. The LHD/SHN is responsible for monitoring and implementing the recommendations of the SAER investigation. The NSW Ministry of Health (MoH) and the CEC oversee SAER investigations across the state to ensure lessons are shared with the broader health system where appropriate.

The term SAER was introduced in the revised Incident Management Policy published in December 2020 and covers the four review methods for serious incidents in NSW Health facilities: Comprehensive Incident Analysis, Concise Incident Analysis, London Protocol and Root Cause Analysis (RCA). Prior to December 2020, only RCA was used to investigate serious clinical incidents in NSW Health. All serious clinical incident investigations presented in this reporting period relate to RCAs.

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 July – December 2020 reporting period).

The MoH is notified of SAC/Harm Score 1 incidents, including Sentinel Events, and other significant clinical incidents. Incidents are reported 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 considered wholly preventable and result in serious harm to, or the death of, a patient. Eight Sentinel Events were required to be reported in Australia between April 2004 and June 2019, as follows:

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
8. Infant discharged to the wrong family.

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

Data on Sentinel Events is reported in the annual Report on Government Services (ROGS). Data for 2019-20 were published in the ROGS report released in February 2022.

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 SAER data.

During the reporting period, all NSW Health services commenced use of ims+. Due to the differences between the IIMS and ims+ applications 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 contained in IIMS and ims+. 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 (Between the Flags) and addressing patients with sepsis (SEPSIS KILLS).

The CEC continues to work with the 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, SAERs, Riskman and Health Information Exchange (HIE). For more specific extract information, please contact the CEC Patient Safety Directorate via email CEC-patientsafety@health.nsw.gov.au

This report contains:

• An explanation of how to interpret the data and information;
• Clinical incident notification data by SAC/Harm Score
• System and risk factors in serious clinical incidents identified through SAER investigations
• Specific clinical incidents involving:
  • Patient Identification
  • Sentinel Events
• Complaints notified in IIMS and ims+.

Data Interpretation

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 influence incident reporting. Incident rates or reporting counts 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 interpretation of the data is recommended.

References

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