DGD12-047
Procedure
Significant Incidents
PurposeThe purpose of this Procedure is to ensure:
· the Health Directorate adopts a proactive, consistent and timely systems-improvement approach to the management of Significant incidents to prevent incident recurrence and minimise risk;
· consistency in definitions, and
· awareness of external reporting requirements, legal and regulatory requirements.
All significant incidents must be notified verbally to the Director General within 12 hours and a written report submitted through the Riskman Incident Notification and Reporting module within 1 working day of the incident occurring.
A significant incident is defined as an incident with an extreme or major outcome* occurring in relation to Health Directorate services and care. All Significant incidents undergo in depth investigation by or after consultation with the Health Directorate’s HealthCARE Improvement Division (HCID).
*Note: incidents with extreme and major outcomes are outlined in the Incident Outcome table within this policy.
ScopeThis procedure applies to all staff of the Health Directorate, including contractors.
ProcedureFeedback and Communication
Feedback and communication of an incident relates to the entire process and is an important mechanism to improve processes and prevent reoccurrence.
Feedback about significant incidents is provided to consumers in accordance with the limits on the disclosure of protected and sensitive information under the Health Act 1993 (ACT), Health Directorate Public Interest Disclosure Policy, and related procedures for complaints management, Health Directorate Privacy and Confidentiality Procedures and the Health Open Disclosure Procedure.
A copy of the initial and final significant incident reports will be emailed through Riskman to the relevant Executive Director. Note: Interim reports will be provided by exception only, with submission determined by incident investigation findings at this timeframe.
The Director General and/or Deputy Director General may provide feedback to the relevant Executive Director via the journal entry section in Riskman once each initial, interim and final report is submitted. To ensure the Executive Director receives this, the journal is allocated to the individuals position profile.
Documentation
All documentation of an incident at each step should occur in the electronic incident form in Riskman and in the Clinical Record (if an incident relates to a consumer). Documentation in Riskman should be in the same manner as the Clinical Record.
Step 1: Identification
Significant incidents may be identified by anyone and can be summarised as those that meet the criteria for a:
A. Extreme incident
B. Major incident, or
C. High risk incident.
A. EXTREME INCIDENTS:Category / Incident or event resulting in:
People / · Death of a worker*/visitor following a workplace incident
Clinical / · Patient death unrelated to the natural course of the underlying illness and/or differing from the immediate expected outcome of patient management
· Death of a client in custody (under a Mental Health order (e.g. EA, ED3, ED7 or PTO) or police custody);
· All national core sentinel events (see definition of terms)
Property & Services / · Loss of an essential service resulting in shutdown of a service unit or facility
· Disaster plan activation
· Destruction or damage to property requiring significant unbudgeted expenditure
Financial / · Loss of 25% of budget or between $200M- $500M
Information / · Complete permanent loss of all Health Directorate or divisional/service records and data
Business Process & Systems / · Critical system failure, bad policy advice or on-going non-compliance. Business severely affected.
Reputation / · Claims made by the media that have an extreme impact on community perception of the organization
Environment / · Toxic release (i.e. chemical, biological or radiological) with detrimental effect on environment and/or personnel
* Worker includes Health Directorate employed staff as well as volunteers, contractors and students.
B. MAJOR INCIDENTS:Category / Incident or event resulting in:
People / · A hostage situation.
· Three or more workers requiring time off following an adverse event in the workplace
Clinical / · Major and permanent loss of function (sensory, motor, physiological or intellectual) or disfigurement, unrelated to the natural course of the underlying illness or differing from the expected outcome of patient management.
# Hysterectomy as an emergency procedure following childbirth will be assessed on a case by case basis through clinical review process for outcome rating.
Property and Services / · Major damage to one or more services or departments affecting the whole facility – unable to be managed by alternative routine procedures
· Service evacuation causing major disruption of greater than 24 hours, e.g. Fire/flood requiring evacuation of workers/ visitors and patients/ clients (no injury)
· Bomb threat procedure activation, potential bomb identified, partial or full evacuation required (+/- injury)
· Destruction or damage to property requiring major unbudgeted expenditure
Financial / · Loss of 10% of budget or between $10M - 200M
Information / · Complete, permanent loss of some Health Directorate or Division/ Business Unit/Service records and/or data, or loss of access greater than 1 week
· Inappropriate storage or exposure of patient/client or consumer clinical records in a public area +/- breach in patient privacy and confidentiality. (These will be assessed on a case by case basis.)
· Inappropriate destruction of patient/client, consumer or clinical records by a worker
Business Process & Systems / · Strategies not consistent with Health Directorate and Governments agenda. Trends show service is degraded.
Reputation / · Claims made by the media that have a major impact on community perception of the organisation
Environment / · Toxic release (i.e. chemical, biological, radiological) requiring assistance of emergency services with no detrimental effect)
C. HIGH RISK INCIDENTS
A high risk incident can be defined as any:
· Event that would have resulted in a significant incident should it have eventuated (a significant near miss)
· Incidents that could attract significant media attention; or
· Possible significant incidents; (that is, significant incident status is unclear until further review is conducted)
· Incidents Notifiable to Work Safe ACT. These include:
o Serious injury/illness of a worker*/visitor following a workplace incident.
Serious injury/illness means the person is required to have:
- Immediate treatment as an in-patient in a hospital; or
- Immediate treatment for
- the amputation of any part of his or her body; or
- a serious head injury; or
- a serious eye injury; or
- a serious burn; or
- the separation of his or her skin from an underlying tissue (such as degloving or scalping); or
- a spinal injury; or
- the loss of bodily function; or
- serious lacerations; or
- Medical treatment within 48 hrs of exposure to a substance
o A dangerous incident (see definition of terms)
* Worker includes Health Directorate employed staff as well as volunteers, contractors and students.
Step 2: Notification
Staff who notify significant incidents need to be aware that the incident report should be written in the same manner as the clinical record for consistency throughout documents. Information should be objective, accurate and avoid speculation or value judgments. Information can be disclosed to consumers and their families under the Health Record (Privacy and Access) Act 1997 and the Freedom of Information Act 1982 in line with Health Directorate policy and processes.
Communication/consultation will occur between Divisions/Branches/HCID prior to submitting the first Significant Incident Report. Communication will also occur with the patient/family/carers in accordance with the Open Disclosure Procedure.
Notification to WorkSafe ACT must occur immediately following a notifiable incident. In the case of the death of a worker, the incident must be reported by phone immediately. A Notifiable Incident form must be completed and sent to the Workplace Safety Section and WorkSafe ACT. Refer to link to WorkSafe ACT website to access this form: http://www.worksafe.act.gov.au/health_safety.
At any significant incident location which causes effect to property or services, firstly ensure that urgent steps are taken to safeguard both employees and members of the public by removing them from the area before securing the site. Where possible, take photographs of the site and make note of the cause of the damage and any equipment that is damaged and forward to the Insurance and Legal Liaison Unit so that a decision can be made by our insurers as to whether an assessor will be required to attend.
Step 3: Classification
Staff should use the tables above to assist them in classifying an incident in Riskman. Occasionally when incidents are first reported, the outcome is unclear, i.e. it may be unclear as to whether the adverse event is related to the natural course of the underlying illness or differs from the immediate expected outcome of patient management. This poses a risk of artificially inflating the significant incident numbers.
Following investigation of the incident, the HCID delegate responsible for submitting the Significant incidents will review the findings. Those incidents may be found as:
· Not having a catastrophic or major outcome; and/or
· Not being in line with the definition of a significant incident
These incidents will be downgraded from the Significant Incident status. Changes in status will be communicated back to the relevant Executive Director.
Step 4: Investigation
All significant incidents undergo in depth investigation by or after consultation with the Health Directorate’s Quality and Safety Unit. Executive Directors will ensure that:
· All extreme and major clinical significant incidents affecting consumers are investigated in accordance with the relevant clinical review processes.
· All extreme and major significant corporate incidents are investigated with the assistance of relevant expert staff (appropriate to the incident) to identify the cause and make recommendations to reduce further risk. Loss of services or environmental incidents should be investigated in accordance with Business and Infrastructure management systems. Incidents involving workers are investigated in accordance with Workplace Safety Section processes outlined in the Safety Management System.
· All significant incidents must have investigations complete and recommendations finalised by the relevant review committees within 100 calendar days of the incident being notified through the incident notification and reporting module in Riskman.
Incidents will also be reviewed within the relevant Division/Branch for potential risk to the organisation (in which case they may be considered for inclusion on the appropriate Division/Branch risk register/s).
Step 5: Action
Actions are developed and implemented following an investigation and should be developed to prevent recurrence of an incident. Actions and follow-up need to be finalised by the responsible manager on Riskman and any changes to local procedures documented accordingly.
Step 6: Evaluation
When all recommendations are implemented and given time to imbed into practice, the local area should evaluate the effectiveness of the strategies. This is to ensure that:
· the systemic problems identified have been addressed
· recurrences have been reduced or eliminated
· lessons have been learned and communicated
· identified barriers to change have been removed
· the loop is closed to ensure organisational learning
A number of strategies can be used to evaluate the implementation, including a risk assessment and monitoring of incident data for similar incidents.
EvaluationOutcome Measures
· Initial Significant Incident Briefs (SIBs) are reported within 1 working day of the incident occurring.
· Final SIB updates submitted with 100 calendar days of incident occurring.
Method
· The HCID monitor internally and escalates as appropriate.
· Legislation
o Health Act 1993 (ACT).
o Human Rights Act 2004 (ACT)
o Freedom of Information Act 1989
o Safety Rehabilitation and Compensation Act 1988
o Work Health and Safety Act 2011
o Work Health and Safety Regulation 2011
o Public Interest Disclosure Act 1994 (ACT)
o Work Health and Safety Codes of Practice
· Standards
o ACHS EQuIP 5, Support, Criteria 2.1.2 & 2.1.3
o Australian Commission on Safety and Quality in Healthcare – National Safety and Quality Health Service Standards
o Open Disclosure Standard: a National Standard for Open Communication in Public and Private Hospitals, Following an Adverse Event in Health Care 2003 (under review)
o Risk Management Standard (ISO 31000:2009)
o Australian Charter of Healthcare Rights
· Policies and Standard Operating Procedures (SOPs)
o Health Directorate “Incident Management” Procedure
o Health Directorate “Significant Incidents” Procedure
o Health Directorate “Open Disclosure” Procedure
o Health Directorate “Look Back” Procedure
o Health Directorate “Consumer Feedback Management” Policy
o Health Directorate “Risk Management” Policy, Procedure and Guidelines (under review)
o ACT Health Clinical Review Process Framework (2008) (under review)
o Little Company of Mary Health Care, Significant Events Policy
o Little Company of Mary Health Care, Clinical Governance Framework
o Little Company of Mary Health Care. Incident, Accident and Near Miss
o Health Directorate Records Management Policy
o Employees Assistance Program Policy
o Preventing and Managing Aggression and Violence Policy
o Health Directorate Public Interest Disclosure Policy (under review)
o Mental Health, Justice Health and Alcohol and Drug Services policy: “Incidents Reportable to the Director of Mental Health” (under review)
o Health Directorate Safety Management System (under review)
Definition of Terms (only use this section if needed, delete if not needed)Adverse event / an incident in which harm resulted to a person receiving health care.
Dangerous incident / any incident in relation to a workplace that exposes a worker or any other person to a serious risk to a person's health or safety emanating from an immediate or imminent exposure to:
· an uncontrolled escape, spillage or leakage of a substance
· an uncontrolled implosion, explosion or fire
· an uncontrolled escape of gas or steam
· an uncontrolled escape of a pressurised substance
· electric shock
· the fall or release from a height of any plant*, substance or thing
· the collapse, overturning, failure or malfunction of, or damage to any plant that is required to be authorised for use in the regulations
· the collapse or partial collapse of a structure