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Patient incident management

The Patient Incident Management and Open Disclosure Policy Directive (PDF 1.9MB) describes a standardised system for managing patient incidents and open disclosure.

The term incident management includes all the activities involved in the reporting, notification or documentation of an incident or near miss; and the review, investigation and analysis of the individual incident or groups of incidents, for the purpose of improving the safety and quality of the health service and the care provided.

A patient incident is any event or circumstance which could have (near miss) or did lead to unintended and/or unnecessary psychological or physical harm to a patient, that occurs during an episode of health care.

SA Health promotes an open and positive approach to incident management, and recognises that most incidents occur because of problems with systems, rather than with individuals.

The Patient Incident Management toolkit includes resources that have been developed for staff to report, investigate, analyse and take action to prevent recurrence of an incident.

The Patient Incident Management toolkit

The Patient Incident Management toolkit will assist staff to implement the policy into practice.

Tool 1 – SLS (Safety Learning System) guide – How to report a patient incident (PDF 483KB)

This is one of series of guides for new users of Safety Learning System (SLS). It describes and illustrates the steps to report and classify a patient incident online into SLS. Key features of SLS are explained.

Tool 2 – Safety Assessment Code (SAC) matrix (PDF 158KB)

The SAC matrix assists readers to assign a SAC rating to a patient incident, based on the actual consequence, and the likelihood of a similar incident occurring. Additional explanatory information is included.

Tool 3 – SLS (Safety Learning System) guide – How to manage a patient incident (PDF 256KB)

This is one of series of guides for managers about Safety Learning System (SLS). It describes and illustrates the steps to classify and manage (review, investigate and analyse) a patient incident in SLS. Key features of SLS, SAC rating and legal considerations are explained.

Tool 4 – Reporting and management requirements for Safety Assessment Code (SAC) 1 and SAC 2 patient incidents flowchart (PDF 81KB)

This flowchart illustrates the steps in the reporting and management of SAC 1 and 2 rated patient incidents. These harmful incidents have additional requirements for notification to senior managers, and may require additional investigation.

Tool 5 - Diagram of incident management and open disclosure (PDF 70KB)

This diagram illustrates all steps and components of patient incident management, encircling the principles for open disclosure with patients and carers.

Tool 6 - Glossary of terms (PDF 96KB)

This document provides additional definitions and information about terms used in the Patient incident management and open disclosure policy directive, and the accompanying policies and tools.

Using Safety Learning System (SLS) for patient incident management

The Safety Learning System is the system SA Health uses for reporting Patient incidents and near misses, and for recording and managing the investigation of incidents.

It is an interactive system that has functions and capability that can:

  • assist notifiers to provide accurate information
  • assist Patient Incident Managers in their role, and monitor progress with incident management
  • safely store and record the information
  • allow information to be shared between staff directly involved
  • provide governance committees and senior managers with tailored reports summarising groups of incidents and data for use in monitoring and planning quality improvement.

Education and training

It is expected that all staff will complete the online eLearning course on Patient Incident Management and open disclosure. Access is available via the DHA Safety and Quality intranet page.

Health services should use the resources in the patient incident management toolkit to guide incident management and quality improvement.

Resources that can be used for education and training about using the SLS for reporting and managing patient incidents is available on Patient incident management in Safety Learning System page.

This includes SLS Guides such as Tool 1 - How to report a patient incident (PDF 648KB), and Tool 3 - How to manage a patient incident (PDF 775KB). There are also an increasing range of SLS Topic Guides that include tips and information about reporting specific types of incidents, for example falls, pressure injuries, restraint and incidents involving medical devices.

Further information is available:

Contact

SA Health Safety and Quality Unit
Michele Sutherland
Telephone: (08) 8226 9599
Email: Safetylearningsystem@sa.gov.au

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