Introduction and background
The Clinical Excellence Commission (CEC) Patient Safety Program is aligned with the NSW Patient Safety and Clinical Quality Program, which seeks to deliver a standardised, system-wide approach to ongoing improvements in the safety and quality of health care provided across the NSW health system. A key component is analysis of statewide clinical incident data within the Incident Information Management System.
An important part of the patient safety program is to inform and work with NSW Health, Local Health Districts and clinical groups to address the patient safety issues identified during review of aggregated data.
The Patient Safety Team utilises the electronic Incident Information Management System (IIMS) to identify risks to patient safety, as reported by NSW Health staff. These insights help to determine where statewide improvements to clinical care can be made. The information obtained from IIMS data analysis has been the basis for many CEC projects and continues to highlight emerging issues across the public health system.
IIMS provides a wealth of information about how NSW Health staff address risks to safe and effective patient care. Root Cause Analysis (RCA) of serious incidents provides further detail of where clinical care systems can fail. The patient safety team recognises that the greatest benefit of the incident reporting system is provision of timely and open feedback to clinical staff, their managers and the patients and families they care for. In this way we can work together to provide the high level of clinical care for which NSW Health is recognised.
The Taxonomy Checklist provides a range of factors to consider when reviewing ED RCAs. It also provides appropriate vocabulary to describe ED specific situations. In particular, the IAC reviews of ED RCAs have found significant variation in how ED staff skill levels are described within RCA reports. For example, the terms ‘Medical Officer’ or ‘Doctor’ provide limited value for assessing the skills and so operation of an ED team. For ED incident analysis purposes it would be more meaningful to know if a Doctor was a RMO or Intern compared to a Staff Specialist for instance. The Checklist provides a list of ED staff skill levels that we would recommend for use in RCA Reports (prepared by Review Teams). There are also other sections to cover Access Block and overcrowding that provide similarly useful vocabulary.
Characteristics of good quality RCA Reports
developed and endorsed by the ECI Incident Advisory Committee
The ED RCA Taxonomy Checklist prompts reviewers to consider the quality of an RCA report. This document summarises findings from a review of the best-rated ED RCA reports and provides suggestions to enhance the production of future RCA reports. The list is of value to use alongside the existing template for RCA reports, and also specific legislation and policy that is relevant to RCA teams (e.g. S.20O (3) of the Health Administration Act 1982 NSW and Health Incident Management policy).
Further References and Resources
- Incidents are given a Severity Assessment Code (SAC) of 1 to 4. This matrix sets out how to classify incidents.
- Incidents and their reporting are subject to policies and procedures, set out in the NSW Health Incident Management Policy (and directive).
- London Protocol: Systems analysis of clinical incidents - this outlines a process for incident investigations and analysis for use by RCA teams.
- The definition of an RIB is set out in Policy Directive PD2014_004.
- Murray, M and McCarthy, S (2017) Review article: A systematic review of emergency department incident classification frameworks, Emergency Medicine Australasia, doi: 10.1111/1742-6723.12864
- Various Clinical Focus and Patient Safety Reports have been produced following the review of RCAs and IIMS data.
- This Clinical Excellence Commission report provides a detailed analysis of the first year of IIMS (2005/6)
- Presentation by Matthew Murray at the ECI ED Leadership Forum 13 March 2015, entitled Incident Classifications and Lessons from Abroad
The following Clinical Focus Reports and Patient Safety Reports have been produced by the Clinical Excellence Commission from reviewing RCAs and/or IIMS data relevant to Emergency Departments: