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Managing incidents

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.

Incident tools and policy documents

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.

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

Incident reports and analysis of data

Clinical focus and patient safety reports

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:

© Agency for Clinical Innovation 2021

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