Explanation of key terms

Acute bed day data

Acute bed day data is obtained from System Information and Analytics 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)

Patient incident/incident

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

Harm Score

The rating system for incidents reported in ims+. The Harm Score indicates the severity of the incident and the action required in response (e.g. Serious Adverse Event Review). Harm Score is automatically calculated in ims+. 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.2

ims+

The current online incident management system used within NSW Health services.

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.

Incident Notification / Notification

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

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 recognition and action staff or an unexpected event.

Perinatal

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

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 Directive PD2020_047.

Root Cause Analysis (RCA)

A method used to review and analyse incidents to identify the root causes and factors that contributed to an incident, and recommended actions. RCAs are subject to statutory privilege under section 23 of the Health Administration Act.

Sentinel Event

A preventable patient safety incident resulting in death or serious patient harm.

Serious Adverse Event Review (SAER)

The process by which all serious clinical incidents in NSW Health are investigated. A SAER can take one of four forms: Root Cause Analysis (RCA), Concise Incident Analysis, Comprehensive Incident Analysis, or London Protocol. SAERs are subject to statutory privilege under section 23 of the Health Administration Act.

Abbreviations

CEC Clinical Excellence Commission
HS Harm Score
MoH Ministry of Health
PIT Principal Incident Type
RCA Root Cause Analysis
RIB Reportable Incident Brief
SAER Serious Adverse Event Review
SIR Serious Incident Review

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

2 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/