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
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