Patient incident management in Safety Learning System
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 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.
After an incident occurs, there are five main actions that together, will improve the safety and quality of care:
- Immediate care and treatment are provided.
- The incident is then recorded into Safety Learning System (SLS) by the notifier.
- The incident is openly disclosed to the consumer.
- The manager reviews this report, investigates the incident and documents action(s).
- The manager and/or relevant committee(s) review data relating to types of incidents, or locations where incidents occur. The data arising from incidents is used to plan improvements to the quality of patient care.
Policy Directive and Toolkit
The Patient Incident Management and Open Disclosure Policy Directive (PDF 1.9MB) describes a standardised system for managing patient incidents and open disclosure.
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.
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.
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.
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 116KB)
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.
This diagram illustrates all steps and components of patient incident management, encircling the principles for open disclosure with patients and carers.
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 with the incident
- provide governance committees and senior managers with tailored reports summarising groups of incidents and data for use in monitoring and planning quality improvement.
Reporting incidents into SLS
All staff can report a patient incident into SLS. Assistance to get started is available on the Safety Learning System page. Staff have a responsibility to report incidents accurately.
SLS Guides and Topic Guides provide information for staff on using SLS to report an incident or near miss. They describe the features and functions of SLS.
- Reporting patient incidents – Frequently asked questions (PDF 100KB)
- Analysing the Contributing factors of an incident (PDF 94KB)
- Tool 1 SLS guide - How to report a patient incident (PDF 1.9MB)
- Challenging behaviour topic guide (PDF 80KB)
- Falls topic guide (PDF 71KB)
- Reporting a patient fall - Frequently asked Questions (FAQs) (PDF 419KB)
- Pressure injuries topic guide (PDF 180KB)
- Restraint and seclusion topic guide (PDF 104KB)
- Maternal and neonate topic guide (PDF 239KB)
- Fact sheet - Improving the quality of maternal and neonatal care by reporting (PDF 71KB)
- Skin tears (PDF 320KB)
- Open Disclosure (PDF 90KB)
- Information Sharing Guidelines (ISG) (PDF 157KB)
- Medical devices or equipment (PDF 537KB)
The Safety Assessment Code (SAC) Matrix (PDF 158KB) will assist staff to rate an incident by considering its outcome (consequence) and the probability of a recurrence.
Classifying Patient incidents
There are 3 levels of classification of the type of incident. Tool 1 – SLS (Safety Learning System) guide – How to report a patient incident (PDF 648KB) provides further information.
The first level types are:
- access, appointment, admission, transfer, discharge
- clinical assessment
- challenging behaviour
- communication and teamwork
- implementation of care
- medical device/equipment
- patient falls and other injuries
- patient information
- pressure injury/ulcer
- staffing, facilities, environment
- treatment, procedure
Classification diagrams can also assist with classification of incidents.
- Maternal incidents classification diagram (PDF 82KB)
- Neonatal incidents classification diagram (PDF 78KB)
In late 2015, the new maternal and neonate classification replaced the single labour and delivery classification. The Maternal classification aligns with the new national definition for maternal sentinel events and Severe Acute Maternal Morbidity (SAMM). These will improve the classification of incidents involving antenatal and post-partum women and their babies.
Information for Patient Incident Managers
Patient Incident Managers have responsibility for the review, investigation, analysis and taking action to prevent recurrence. In some cases Patient incident managers will also need to produce reports of incident data. The roles and responsibilities of Patient Incident Managers are described in the Policy Directive (PDF 1.9MB).
Tool 3 – SLS (Safety Learning System) guide – How to manage a patient incident (PDF 1.1MB) describes the steps to classify and manage (review, investigate and analyse) a patient incident. This guide illustrates the key features and functions of SLS to assist managers. SAC rating and legal considerations are also explained.
Some SLS topic guides provide additional information for managers about specific types of incidents. These include:
- Challenging behaviour topic guide (PDF 92KB) which includes 2 questions to complete after review of the report
- Post fall team review (PDF 73KB)
- Restraint and seclusion topic guide (PDF 104KB) which includes 5 questions to complete after review of the report.
Patient Incident Managers login access
In order to be able to perform these roles, managers will need to apply for 'manager access' to SLS incidents relevant to your work and area of responsibility. Complete the SLS User Access Request form (DOCX 57KB) and forward to your Clinical SLS Site Administrator (PDF 100KB).
Manager’s roles in serious incidents
These harmful incidents (generally SAC1 and SAC 2) have additional requirements for notification to senior managers, and may require additional investigation.
The use of a template for Clinical Incident Brief (DOCX 63KB) was approved by the Acting Chief Executive on 28 December 2016, in order that appropriate executives in the Department for Health and Ageing (DHA) are provided with consistent high quality information, in a timely fashion. This template is for LHNs and statewide services to use for these communications.
There is a Guide for completing a Clinical Incident Brief (PDF 123KB) (CIB). The purpose of this guide is to assist staff to use the template to complete the Clinical Incident Brief (CIB).
Tool 4 – Reporting and management requirements for Safety Assessment Code (SAC) 1 and SAC 2 patient incidents flowchart (PDF 116KB) illustrates the steps in the reporting and management of SAC 1 and 2 rated patient incidents.
This includes incidents that are classified as Cluster Incidents and Sentinel Events. These are all rated as SAC 1 incidents and the local Safety and Quality or Clinical Governance Manager needs to be involved in reporting to CEO, and with the investigation.
Sentinel events are:
- procedures involving the wrong patient or body part resulting in death or major permanent loss of function
- suicide of a patient in an inpatient unit
- retained instrument/s or other material after surgery requiring re operation or further surgical procedure
- intravascular gas embolism resulting in death or neurological damage
- haemolytic blood transfusion reaction resulting from ABO incompatibility
- medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
- maternal death associated with pregnancy, birth and the puerperium
- discharge of an infant to the wrong family.
Committees that have been designated as Part 7 protected committees for Safety and Quality assessments are authorised to undertake investigation of serious incidents.
In certain circumstances a Root Cause analysis (RCA) may be conducted under the protection of the Health Care Act 2008, Part 8.
Cluster incidents are system issues affecting more than five patients. The type of review required is a Lookback review
See the following for more information regarding serious incidents:
- Root Cause Analysis education
- Part 8 of the Health Care Act 2008
- Coronial process and the Coroners Act 2003
- Part 7 protected committees for Safety and Quality assessments
Legal protection of information in SLS
Information recorded in SLS that is related to a patient incident should be considered in the same way that information in a patient medical record (health record) is. That is information should be accurate, succinct, factual and objective.
Information arising from a Part 7 review or an RCA conducted under the protection of Part 8 of the Health Care Act 2008 cannot be released other than in a de-identified format. Please contact Safety and Quality Managers prior to release of any information about incident.
Removal of Part 7 protection of Safety Learning System
On 15 September 2016 the protection of SLS under Part 7 of the Health Care Act 2008 was removed. The Frequently Asked Questions (PDF 320KB) information sheet outlines the effect of this change.
Education and training
It is expected that all staff will complete the online eLearning course on Patient Incident Management and open disclosure. Access is 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.
Further information is available
- Safety Learning System
- Open disclosure information for staff
- Open disclosure information for consumers
SLS is under constant development and review. Notices and information about updates to SLS, training and resources are sent to Safety and Quality Managers and SLS Administrators who then distribute these, as required, to staff affected.
If you would like to receive these Notices, email Safetylearningsystem@sa.gov.au.
In the first instance, contact your local Local Health Network SLS Site Administrator (PDF 100KB) regarding patient incidents.
SA Health Safety and Quality Unit
Michele Sutherland, SLS Team Manager
Telephone: (08) 8226 9599