Patient incident management and open disclosure
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.
The Patient Incident Management and Open Disclosure diagram (PDF 70KB) shows that after a patient incident, there are two separate but linked and related processes to ensure that:
- 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.
In line with Good medical practice: a code of conduct for doctors in Australia, 2014 and other professional codes, SA Health promotes open disclosure with consumers; a quality improvement and non-punitive approach to incident management; and participation by all staff in reporting and learning from incidents.
Actions to take after an incident occurs
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.
SA Health resources
The Patient Incident Management and Open Disclosure Policy Directive (PDF 1.9MB) describes a standardised system for managing patient incidents and open disclosure.
The map of documents and tools for patient Incident Management and Open Disclosure (PDF 61KB) provides a one page list of the current documents and tools.
The guide to using the Patient Incident Management and Open Disclosure toolkits (PDF 108KB) provides a summary of each document and resources that accompany the Policy Directive.
Safety Learning System Patient Incident Module Protection and disclosure
SA Health takes the protection of individuals’ personal information very seriously, and has systems in place to make sure that information is only released once safeguards have been met and in response to authorised requests. For more information visit Safety Learning System Patient Incident Module Protection and Disclosure staff Fact Sheet (PDF 327KB) or consumer fact sheet (PDF 250KB).
National Safety and Quality Service Standard 1: Clinical Governance
The NSQHS Standard 1: Clinical Governance describes actions that need to be met for accreditation:
1.11 The health service organisation has organisation-wide incident management and investigation systems, and:
- Supports the workforce to recognise and report incidents
- Supports patients, carers and families to communicate concerns or incidents
- Involves the workforce and consumers in the review of incidents
- Provides timely feedback on the analysis of incidents to the governing body, the workforce and consumers
- Uses the information from the analysis of incidents to improve safety and quality
- Incorporates risks identified in the analysis of incidents into the risk management system
- Regularly reviews and acts to improve the effectiveness of the incident management and investigation systems
1.12 The health service organisation:
- Uses an open disclosure program that is consistent with the Australian Open Disclosure Framework
- Monitors and acts to improve the effectiveness of open disclosure processes
The SA Health Accreditation Resource Standard 1: Clinical Governance identifies the resources that are available to support each action.
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.
Consumer information and resources are available on the Open disclosure for consumers page.
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.
- open disclosure toolkit to guide the conduct of, and participation in, open disclosure
See the Patient incident management in Safety Learning System page to learn about using SLS.
Using Safety Learning System (SLS) for incident management and open disclosure
Further information about using SLS for reporting and managing patient incidents, and recording open disclosure is available on the Patient incident management in Safety Learning System page.
Additional information is available on the Safety Learning System page.
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.
SA Health Safety and Quality Unit
Telephone: (08) 8226 9599