SAC/Harm Score1 Reportable Incident Briefs (RIBs)
The total number of SAC/Harm Score1 clinical incident notifications has decreased by 13 per cent over the January – June 2020 reporting period. The rate of SAC/Harm Score1 incidents has remained stable since 2016 (refer to Table 2).
The most frequently reported SAC/Harm Score1 clinical incidents continued to be categorised under the Principal Incident Type (PIT) Clinical Management. This category includes incidents related to the diagnosis, treatment, and monitoring/observations of patients in an inpatient care setting (Table 4).
During review of the RCA reports, if the PIT is not clearly identifiable, or the cause of death could not be determined due to unclear circumstances or evidence provided, the RCA Review Committees may apply the PIT 'Undetermined cause of death'.
Table 3: SAC/Harm Score1 Clinical Incidents by PIT, July 2016 – June 2020
|Service or Principal Incident Type*||2016||2017||2018||2019||2020|
|Clinical Management - all clinical streams includes patient identification**||89#||94#||71#||96#||97#||106#||105#||79#|
|Retained accountable items||7||7||5||5||10||7||2||0|
|Behaviour/Human performance (includes suspected suicides)||57||62||42||57||42||46||50||66|
|Maternal and perinatal stream||10||14||15||14||20****||15||22||22^|
|Incidents from all groups determined to be non-preventable or unclassifiable, following RCA||36||32||28||18||44||26||35||22|
Caveats: *SAC/Harm Score1 data obtained from CEC Patient Safety Database
**All clinical streams, includes patient identification errors (see 'Definitions' page)
***Patient identification reporting requirements changed on 10th February 2014
****Includes an incident which involved retained material
†Other includes Blood/Blood Products, Health Care Associated Infection, Medical Devices/Equipment, Medication/IV Fluid, Undetermined cause of death, RCAs not received and RCAs not reviewed
#Includes patient identification incidents
^includes fetal, maternal death and stillbirths