Biannual Incident Report

July – December 2021

Incident Management in NSW Health

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.

NSW Health has reported on incidents since 2005, when the Incident Information Management System (IIMS) was introduced. From October 2019 to December 2020 NSW Health progressively introduced a new system, ims+, to report and manage incidents, hazards, consumer feedback and near misses. St Vincent's Health Network (SVHN) uses Riskman for incident reporting.

Patient-related incidents reported in ims+ have a score applied - Harm Score, which is automatically calculated 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 investigation 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).

In line with the NSW Health Incident Management Policy, clinical Harm Score 1 incidents must undergo a thorough investigation known as a Serious Adverse Event Review (SAER). The approved investigation 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 action taken is tracked by the relevant Local Health Districts (LHD) or Specialty Health Networks (SHN). Lessons are shared with the broader health system where relevant.

Clinicians undertake a structured process to review the incident to identify what happened, how and why it happened, what could be done to reduce risk and make care safer and identify what was learned. The review process enables staff to engage with patient and families in the open disclosure process. Figure 1 provides the framework for the review process during the July – December 2021 reporting period.

The NSW Ministry of Health (MoH) is notified of Harm Score1 incidents, including Australian Sentinel Events (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. Since 1 July 2019, ten ASE types have been determined and are reported nationally. Further information on Sentinel Events can be obtained from the Australian Commission on Safety and Quality in Health Care website.

Figure 1: Serious clinical incidents requiring SAER investigation during the period July – December 2021

Figure 1: Serious clinical incidents requiring SAER investigation during the period July – December 2021

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 monitoring clinical incidents reported in NSW. The CEC analyses incident data to determine priority areas for improvement.

The CEC supports patient safety across NSW through programs and expertise including recognition and management of the deteriorating patient, sepsis, comprehensive care, REACH and Infection Prevention and Control.

NSW Health was the first Australian jurisdiction to publicly report healthcare incident data in 2005. The CEC published its first online 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 obtained from a number of sources including ims+, RIBs, SAERs, Riskman and the Health Information Exchange (HIE). For more specific extract information, please contact the CEC Patient Safety Directorate via email.

This report contains an analysis of patient-related incidents and consumer feedback reports in ims+ and Riskman between July – December 2021. This report builds on the last report (January – June 2021) and will continue to evolve and enable comparison between reporting periods and the identification of trends.

Data contained within this report cannot be compared to data provided in reports prior to 2021, due to changes in reporting including Australian Sentinel Events and NSW Health’s transition to ims+.

This report contains:

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

Data considerations

Analysis of the information contained within ims+ provides greater insight into how incidents occur, provides context, highlights issues and identifies 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 factors influence incident reporting. Incident reporting counts or rates should not be used as the single source of benchmarking data for a project, program, facility or health organisation.

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 conclusions should not be drawn about the relative frequency of events or trends in events over time.

References

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