Patient incident management in Safety Learning System
SA Health promotes an open and positive approach to incident
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
SafetyLearning 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
isused 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 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
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 resources provide information for staff on using SLS to report an incident or near miss. They describe the features and functions of SLS.
SLS topic guides
- Reporting and management requirements for SAC 1 notifiable incidents
- Classifying medication incidents (PDF 227KB)
- Reporting patient incidents – Frequently asked questions (PDF 100KB)
- Reporting challenging behaviour by a patient (PDF 80KB)
- Reporting a patient fall (PDF 419KB)
- Reporting a pressure injury (PDF 180KB)
- Reporting restraint and seclusion of a patient (PDF 104KB)
- Maternal and neonate care (PDF 239KB)
- Reporting skin tears (PDF 320KB)
- Open disclosure processes (PDF 90KB)
- ISG information sharing guidelines (PDF 157KB)
- Medical devices or equipment (PDF 537KB)
- Transfusion of blood products (PDF 332KB)
Frequently asked questions
- Reporting patient incidents (PDF 100KB)
- Reporting a patient fall incident into the safety learning system (497KB)
- Improving the quality of maternal and neonatal care by reporting (PDF 68KB)
- Safety learning system patient incident module protection and disclosure (PDF 323KB)
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.
- Medication incidents classification diagram (PDF 58KB)
- 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
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
reviewof the report
- Post fall team review (PDF 73KB)
- Restraint and seclusion topic guide (PDF 104KB) which includes 5 questions to complete after
reviewof 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).
Managers' roles in serious incidents
These harmful incidents (generally SAC1 and SAC 2) have additional requirements for notification to senior
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
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
- Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death
- Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death
- Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death
- Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death
- Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death
- Suspected suicide of a patient within an acute psychiatric unit or acute psychiatric ward
- Medication error resulting in serious harm or death
- Use of physical or mechanical restraint resulting in serious harm or death
- Discharge or release of a child to an unauthorised person
- Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death
Committees that have been designated as Part 7 protected committees for Safety and Quality assessments are authorised to undertake
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
Removal of Part 7 protection of Safety Learning System
On 15 September
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 113KB) regarding patient incidents.
SA Health Safety and Quality Unit
Michele Sutherland, SLS Team Manager
Telephone: (08) 8226 9599