Glossary

Acute bed day data

Acute bed day data has been provided to the CEC from the Health System Information and Performance Reporting Branch of NSW Health. The following exclusions have been applied for the reports:

  1. Care type is 0 (Hospital Boarder).
  2. Bed types are 25 (Hospital in Home – General), 66 (Delivery Suite), or 67 (Operating Theatre/Recovery).

(Reference for bed types can be found in PD2012_054 Appendix 2.)

Clinical incident/incident

An incident is an unplanned event that results in, or has the potential for, injury, damage, or loss, including near misses.2 An incident may also be referred to as an 'adverse event'.

Harm Score

The system by which the severity of a clinical incident is rated in ims+ and the required response is directed across NSW Health services. More information is contained in the NSW Health Incident Management Policy PD2020_047.

Human Factors

Enhancing clinical performance through an understanding of the effects of teamwork, tasks, equipment, workspace, culture, organisation on human behaviour and abilities, and application of that knowledge in clinical settings.3

Incident Information Management System (IIMS)

An online incident reporting and management system developed in Australia for NSW Health. The St Vincent's Health Network uses a different system called Riskman.

ims+

ims+ the new incident management system currently being implemented across NSW Health services which will replace the IIMS.

Incident management

The cycle of activities required to recognise, report, understand, and reduce the risk of unplanned events occurring. In the health system, feedback to the notifier and sharing of learnings are essential components of this cycle.

Near miss

An unplanned event that did not result in injury, illness, or damage but had the potential to do so. A break in the chain of events prevented harm, due to either staff recognition and action, or a fortuitous event.

Notification

The initial report within IIMS that an incident or near miss may have occurred. All staff are required to report incidents in IIMS and must complete the mandatory fields within the system. Notifications can be anonymous and reflect the information known by the reporter at the time

Patient Safety Watch

A series of focused summary reports based predominantly on incidents which have been subjected to root cause analysis or other investigative methodologies. The aim is to feed the lessons learned back to local health districts and specialty networks, highlighting key risks and recommending preventative actions for local implementation.

Occasions of service

Any instance in which an examination, consultation, treatment, or other service is provided by a health service provider to a patient.

Patient Safety Watch

A series of focused summary reports based predominantly on incidents which have been subjected to RCA or other investigative methodologies. The aim is to feed the lessons learned back to local health districts and specialty networks, highlighting key risks and recommending preventative actions for local implementation.

Perinatal

The perinatal period commences at 20 completed weeks (140 days) of gestation and ends 28 completed days after birth.

Retained accountable items

Unintended material (such as a swab) requiring surgical removal.

Reportable Incident Brief (RIB)

A document used to notify NSW Health of a reportable incident. RIBs are subject to statutory privilege under section 23 of the Health Administration Act. For more information refer to the NSW Health Incident Management Policy PD2020_047.

Root Cause Analysis (RCA)

The RCA method identifies root causes, contributing factors, and/or systems issues which may have contributed to clinical incidents. Recommendations are made by RCA investigation teams to reduce the risks identified, prevent similar incidents in future, and inform system improvements.

Severity Assessment Code (SAC)

The system by which the severity of clinical incidents and complaints are rated in IIMS and the required response is directed across NSW Health services. More information is contained in the NSW Health Incident Management Policy PD2020_047.

Abbreviations

CEC Clinical Excellence Commission
EBM Expressed Breast Milk
PIT Principal Incident Type 
RCA Root Cause Analysis
RIB Reportable Incident Brief
SAC Severity Assessment Code

2 Organisation for Economic Co-operation (OECD) (2017)

3 Dr Ken Catchpole, Cedars-Sinai, 'How to' guide: volume 2 Implementing Human Factors in healthcare 'Taking further steps', https://chfg.org/how-to-guide-to-human-factors-volume-2/