SA Health recognises that incidents can occur while providing health care, some of which may have serious consequences for consumers.
Effective incident management and open disclosure processes are attributes of high-quality health service organisations, and important elements of quality improvement and a consumer or patient-centred approach to healthcare.
patients and their family/carer can contribute to the investigation, and are informed of the recommendations arising and actions taken or planned to prevent recurrence and improve safety and quality of the service
health services learn from the investigation and analysis of incidents and from the perspective of the consumer/patient and their family/carers.
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.
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.
Incidents that have serious adverse outcomes for consumers may require:
The open disclosure of incidents is an important part of the incident management process and is essential to a consumer-or patient-centred approach to care.
Open disclosure is the process of providing an open, consistent approach to communicating with patients/consumers, their family, carer and/or support person following a patient incident. This process includes expressing regret or saying sorry.
The Open disclosure toolkit includes resources have been developed for staff to manage the open disclosure process for level 1 (SAC 1 and 2) and level 2 (SAC 3 and 4) incidents.
Each health service has staff with expertise in incident management and open disclosure. They have roles in Safety and Quality, Clinical Governance and/or Risk Management. Queries should be addressed to these staff in the first instance.
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