A clinical incident is any unplanned event which causes, or has the potential to cause, harm to a patient. NSW Health staff are required to report all incidents, so that risks to patient safety are recognised and action is taken to prevent recurrence.
The clinical incident reporting system in the NSW public health system is called the Incident Information Management System (IIMS). The IIMS database contains all the information collected since state wide clinical incident reporting was implemented in 2005. Incidents reported in IIMS and Riskman are classified according to one of 19 Principal Incident Types (PITs), and then further classified against a Severity Assessment Code (SAC). As a lead agency for quality and safety improvement in the NSW public health system, the CEC has a key role to play in analysing and reporting on the information provided from the incident monitoring system. The CEC published its first web-based clinical incident management report in 2013, outlining bi-annual data summaries from January 2010 to December 2012.
The greatest benefit of IIMS analysis is the narrative, which helps highlight issues and system-related opportunities for improvement.
The number of clinical incident notifications in the Incident Information Management System (IIMS), and Riskman for St Vincent's Health Network, continued the upward trend noted in previous reports with an 18.7% increase in the four years between July 2010 and June 2014 (Table 1). Clinical incidents notified in IIMS and Riskman are allocated a Severity Assessment Code (SAC) rating in accordance with NSW Health Incident Management Policy PD2014_004. Reporting the number of clinical incidents in relation to the activity of the facility (per 1,000 bed days) provides greater insight than from incident rates alone.
Figures 4 and 5 show the number of clinical incident notifications per 1,000 acute care bed days from July 2010 to June 2014. When a notification of a clinical incident is made, the principal type of incident is recorded.
The most frequently notified SAC1 incidents from July 2010 to June 2014 continued to be associated with diagnosis, patient identification and treatment of patients in any inpatient care setting. As expected SAC1 Clinical Management notifications have significantly decreased following the release of the updated NSW Health Incident Management Policy PD2014_004 which no longer requires the incorrect patient, procedure or site incidents to be automatically classified as a SAC1 notification. Root Cause Analysis (RCA) investigation is a method used to identify the underlying cause and contributing factors of an incident. The three system factors identified by the RCA review committees have consistently involved communication, care planning and policy and guidelines. Care planning relates to incidents where there may have been gaps or failures in collaborative planning for patients receiving care from more than one team, including private providers, inpatient and community-based services. Private health facility RCAs are included, when provided by the private facility & represents RCA reports received during the specified reporting period. Previous clinical incident management reports have also considered the impact of incomplete communication when care is handed over from one care provider to another. Care planning, workforce, assessment and communication are the most frequent system issues identified by the Maternity and Perinatal RCA committee in the July to December 2013 reporting period.
The clinical risk factors in the RCA review process relate to the conditions or situations that patients may, or have been exposed to, that could increase their risk of serious incident or harm occurring. The identification and prompt management of deterioration is a risk factor identified by all RCA committees. Patient identification incidents refer to incidents associated with the matching of the correct patient, site and procedure.
In NSW, incidents prior to 2014 that involved the incorrect patient, procedure, body part or surgical implant were classified as serious incidents (SAC1) in IIMS and subsequently underwent RCA investigation. Classification and review of the findings from Root Cause Analysis (RCA) investigations for incorrect patient related incidents were reviewed and classified to inform work undertaken to strengthen systems for correct patient procedures.
The CEC's Falls Prevention Program has produced a range of initiatives that have been introduced throughout NSW hospitals to prevent falls and the harm associated with falls. Although reporting of falls outcome is not mandatory, 54 per cent of fall incidents had outcomes recorded. The use of medication is the most common intervention in the NSW health care system and is one of the greatest risks to patients if errors are made. Consistent with international findings, incidents associated with medication administration are the most commonly reported medication incident type in NSW during 2013, followed by medication prescribing incidents. A dispensing incident classification includes those incidents that involve the dispensing of medication from the pharmacy.
In 2013, less than one per cent of medication incidents notified were rated as SAC1 or SAC2 incidents.
Fortunately, most medication incident notifications are for incidents in which there was no harm to the patient.
During 2013, opioids and anticoagulants were the medications most frequently involved in the more serious (SAC1 and SAC2) medication incidents.
The CEC's High-Risk Medicines Program aims to heighten awareness of the harm that can be caused by these medicines and provide action-oriented information to assist clinicians in improving their management. The CEC's Paediatric Quality Program supports and improves the care of infants and children up to 16 years of age (or young people, over 16 years of age still being cared for in one of the three children's hospitals within NSW).
The six most prevalent principal incident types for children 0-16 years are shown in Figure 17. The top three medications involved in paediatric medication incidents are Paracetamol, Morphine and Gentamicin. Figure 18: Medications involved in Paediatric Clinical Incidents, January - June 2014* Note in this list of top medication several are used almost exclusively in neonatal care, namely Vitamin K1, Hepatitis B vaccine and Caffeine. Medication incidents are among the most frequently reported incidents making medication safety in children and young people an area of focus for the Paediatric Quality Program in 2015.

In the period 1 January 2012 to 25 March 2014 a total of 94 hospital-associated incidents of VTE were reported in IIMS.
Only 33 per cent of the known actual SAC1 incidents were identified from IIMS extraction as the principal incident type, the other 66 per cent were recognised through analysis of the narrative.
This demonstrates the low reporting rates of hospital-associated VTEs, as these incidents are often viewed as a complication and rarely reported as an incident. Encouraging staff to engage with patients and families during the provision of health care is known to improve communication, and results in a better experience of care. When reviewing clinical incident and complaint notifications against occasions of service, the proportion of both clinical incidents and complaints remained constant over time (Figure 23). The field of study concerned with the design of systems or processes to take proper account of the capabilities and limits of the people working within that system.
Is a series of focused summary reports based predominantly on incidents which have been subjected to root cause analysis or other investigative methodologies. The classification system within IIMS which assists the incident reporter to describe the incident. The system by which the severity of an incident is rated and the required response is directed across NSW Health services.
This is used to classify incidents related to accidents, occupational health and safety, or the physical environment and staff incidents. This is used to classify the details of the aggressive incident, in the context of the aggressor. This is used to classify the details of any incident involving the provision of patient, staff and visitor services, or the organisational management of the health care institution. This is used to classify the details of incidents directly related to the security of the organisation. The Incident Management System (IMS) will replace the current NSW Health incident management tool known as the Incident Information Management System (IIMS) to improve the ability to effectively record, track, manage and report on clinical and corporate incidents, including actions taken to address the issue and mitigate existing risks. The new IMS being delivered by the Clinical Excellence Commission in collaboration with eHealth NSW, aims to enhance incident reporting by providing increased functionality and a more user-friendly interface.
The new solution is intended to make it easier for staff to notify incidents, near misses and system risks, through implementation of a user-friendly platform, which interfaces with other relevant NSW Health systems. More information about clinical incident management in the NSW public health system can be found on the Clinical Excellence Commission website. In addition, the CEC publishes the outcomes from projects and programs developed in response to clinical incident reporting, such as Between the Flags and SEPSIS KILLS. This work is part of the CEC's commitment to building confidence in health care in NSW, by making it demonstrably better and safer for patients and a more rewarding workplace. The most serious types of clinical incidents are rated as SAC1 (the other possible scores are SAC2, SAC3 or SAC4 in declining order of severity). The rate of incidents per 1,000 acute bed days is consistent with previous incident reporting periods.
A reportable incident brief (RIB) is still required for all incorrect patient, procedure site incidents regardless of outcome.
It also aims to develop appropriate clinical and management responses and system improvements which could prevent similar incidents in the future. These reviews allow for some variation and assist in the identification of system-level themes across different practice areas and facilities that have state-wide implications. Care planning also incorporates incidents which arise when a patient's co-morbidities, falls risk, or the capacity of their carers to manage ongoing care have not been adequately assessed or addressed. These three system factors have consistently remained the top three, although over each reporting period their individual rates have equally fluctuated with increases in the July to December reporting period. The CEC's Between the Flags system addresses the problems associated with failure to recognise, escalate and respond to patient deterioration by providing a suite of standard observation charts which incorporate standard calling criteria to escalate care of the patient. The CEC is reviewing in closer detail this type of incident notification and is liaising with specialty groups to develop a Clinical Focus Report to highlight the risk, best practice and recommendations to improve care and management.
A formal RCA investigation may not be required, however a reportable incident brief (RIB) to the NSW Ministry of Health remains a requirement. In 2013 there was no significant change in the number of incidents involving incorrect patient, procedure, body part or surgical implant. Information is collected in IIMS that provides details on the type and classification of medication incidents and the medications involved. The CEC Medication Safety and Quality Program aims to reduce administration and prescribing incidents by assisting health care teams to work together to improve their local medicine-use systems.
A medication administration classification includes incidents involving the direct administering of the medication to the patient by clinical staff.
An administration incident is classified to include those medication incidents that relate to the provision of the medication to the patient.
Sixty-five percent of all medication incidents received the lowest severity rating (SAC4), a further 30 per cent were identified as SAC3, and the remaining four per cent represent incidents that had no SAC score applied (Table 19).
Medicines most frequently involved in medication incidents during 2013 included opioids (such as oxycodone, morphine and fentanyl), insulin, and anticoagulant medicines (such as warfarin and heparin) (Table 20).
For example, in response to serious incidents reported involving 'ten-fold dosing' errors, (i.e.
Several of these areas are being addressed through existing CEC programs, including Medication Safety, Quality Use of Antimicrobials in Healthcare, Falls Prevention Program, Between the Flags and SEPSIS KILLS.
Incidents involving these three medications will be a focus for the paediatric and quality program during 2015.
While hospitalisation is a major risk factor in the development of VTE, incidents are often not reported.

This illustrates the importance of reviewing the incident narrative when analysing IIMS data and having a standardised method of investigating incidents involving VTE. Only 3.9 per cent (45 out of 1152) of the known incidents of hospital-associated VTE were reported through the voluntary IIMS reporting system during 2012.
Feedback from consumers of health care services, their families and carers is actively encouraged. The CEC's Partnering with Patients program was established in 2010 to work with local health districts to help include patients and family as care team members, improve consumer engagement and promote safety & quality in health care.
Feedback from consumers on their experience in the public health system contributes to ongoing service improvement.
Access complaints highlight consumers' concerns about demands on the health care system (Table 27).
A small number were received via other entities, including the Health Care Complaints Commission (8%), Minister and Members of Parliament (5%), and Ombudsman (1%). A list of possible types is available within the clinical incident management system for selection. In the health system, feedback to the notifier and sharing of learnings are essential components of this cycle. All staff are required to report incidents in IIMS and must complete the mandatory fields within the system.
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.
This classification does not capture information related to surgical complications or incidents. All SAC1 incidents are subject to a thorough investigation known as a root cause analysis (RCA), to find out what happened and identify opportunities to make health care services safer (Figure 1). Caution is advised if using IIMS reporting counts or rates as the single source of benchmarking data for a project or program, as many variables influence incident reporting. This coincides with the release of the updated NSW Health Incident Management Policy PD2014_004 which now allows incorrect patient, procedure or site incidents to be classified as a lower score according to the consequence and SAC matrix.
During this time, the ratio of SAC1 incidents per 1,000 acute care bed days (Table 2) has remained relatively stable. Between the Flags also includes minimum standards for escalation including processes for both Clinical Review and Rapid Response in all NSW Health facilities.
This is in recognition of the potential serious risk to patient safety inherent in such incidents, although in most cases there is no actual harm caused to the patient. Reporting of this type of incident continues via RIB to maintain vigilance and awareness for ongoing system improvement. Twenty one percent of medication incidents involved a prescribing error such as illegible writing; incomplete prescriptions or errors made on the prescription itself, and 12 per cent involved a dispensing error.
Incidents reported in IIMS provide details on some of the underlying contributing factors to this adverse event, while Health Information Exchange (HIE) coded data, extracted from hospital patient admission systems, was found to provide a more indicative view of the actual rates of hospital-associated VTE.
Table 22 provides a summary of the severity rating (or SAC codes) of the incidents identified. This again demonstrates that a more standardised method of investigating these incidents is required. The programs support NSW hospitals in implementing VTE prevention strategies to reduce the incidence of hospital-associated VTE. Complaints received are entered into the Incident Information Management System (IIMS) and Riskman for St Vincent's Health Network. Local heath districts, NSW Ministry of Health, official visitor and other made up the remaining 11 per cent. A selection list is available within the clinical incident management system for selection. For more information, see PD2006_058 Authorised Research and Investigation under the Health Administration Act 1982 and the NSW Health Incident Management Policy. While an initial SAC may be applied, the actual SAC must be applied within five days of the incident notification.
The increased number of notifications for less serious incidents suggests that incident reporting is embedded into the practice of clinicians and managers in NSW Health services.
Staff are maintaining a positive reporting culture as the public health system manages escalating demands for acute and increasingly complex care. All SAC1 clinical incidents (and SAC2, SAC3 or SAC4 incidents deemed to benefit from the RCA process) undergo a RCA investigation. The RCA review committees are provided with the RCA reports 70 days after the incident occurs and are then reviewed at scheduled meeting over the following six month period. The new changes in SAC rating requirements for incorrect patient, procedure and site incidents is reflected in the decreased January to June 2014 reported data. The CEC Falls Prevention Program provides information and resources to assist in risk assessment, falls prevention and management. All SAC1 incidents and national sentinel events require a reportable incident brief to be submitted to the NSW Ministry of Health within 24 hours of notification of the incident in the IIMS. In nearly all cases, underlying system failures are found to have contributed to, or failed to stop errors during complex care processes.

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