Action 1.11

Incident reporting can improve safety (especially when it is based on a cycle of quality improvement), improve care processes, change the way clinicians think about risk and raise awareness of good practice. The nature of the risks faced by organisations varies according to the type of organisation and the context of service delivery. This highlights the importance of evaluating the effectiveness of incident management and investigation systems at the local level.¹

Review the incident management and investigation system

A well-designed incident management and investigation system should support the workforce to identify, report, manage and learn from incidents. The system should comply with legislative requirements and with state or territory clinical incident management policies.

A well-structured system would generally incorporate the following elements:

• A clear policy framework that defines the key elements of the system; the roles and responsibilities of individuals and committees; the type of events to be reported; the process for reporting, investigating, analysing and monitoring clinical incidents; and the responsibility of clinicians to report incidents they observe or that arise from the use of healthcare records, including digital healthcare records
• A focus on managing each incident appropriately from a clinical perspective and ensuring the provision of safe, high-quality care to the patient following the incident, including open disclosure, if appropriate
• A designated individual with responsibility for maintaining the integrity of the system and coordinating incident management
• Adequate and appropriate systems (including relevant equipment and technology) to support incident reporting and analysis
• Workforce responsibilities for managing reported incidents, including grading their severity and leading further investigations
• Policies, procedures and protocols regarding confidentiality of information and the ability of members of the workforce to report anonymously
• Responsibilities for analysing incident data, and identifying trends and opportunities for improvement
• Responsibilities for disseminating information about incidents and their quality improvement implications
• Responsibilities for following up incidents to ensure that improvements have been made, if appropriate; this may include ensuring that information about relevant incidents is incorporated into the organisation’s risk management processes
• Responsibilities for reporting incidents to other parties (for example, health departments) under the relevant organisational obligations
• Links to the organisation’s open disclosure, risk management, and credentialing and scope of clinical practice processes; the state or territory incident management and investigation system, if applicable; and the procedure for communicating with the organisation’s professional indemnity insurers.

Support the workforce

Leaders, including clinical leaders, should encourage the workforce to use the incident management system to report clinical incidents, near misses and adverse events.

Engaging the workforce to find solutions to issues is important for improving safety¹, especially when the improvement actions require coordination across teams or departments.

Provide information about the intent and use of the organisation’s incident management and investigation systems to the workforce at orientation and routinely throughout their employment.

Support patients, carers and families

Support patients, carers and families to communicate their concerns by:

• Distributing information to patients and carers about what incidents and concerns are, and how to report them
• Training the workforce on how to respond to patients or carers who raise concerns or report incidents
• Providing, when possible, appropriately skilled members of the workforce to liaise with patients or carers who report concerns or incidents
• Conducting patient experience surveys or seeking feedback on safety incidents on discharge
• Providing information about improvement activities that have been implemented based on patient feedback.

Report on, and review, incidents

Provide comprehensive information to the governing body and management on all serious incidents, and summary information about all other incidents. Include information such as the actions taken as a result of a specific incident or category of incidents, and indicators such as time to complete actions stemming from incident reports. This will enable governing bodies and management to fulfil their governance responsibilities.

Define a reporting framework that clearly identifies the data that will be available and reported at each level in the organisation. This will enable members of the workforce and the governing body to monitor and respond to system performance.

Ensure that the system facilitates timely and effective review of information about clinical incidents, and that information is used at all levels of the organisation to improve the safety and quality of care.

Ensure that each incident is reviewed by the clinicians involved and the manager responsible for the operational area in which the incident occurred. This enables lessons to be learned and local improvements to be implemented. A system to verify that managers follow up incidents appropriately will ensure integrity of the risk management system.

Set up classification and escalation processes to ensure that serious incidents, and incidents associated with major risk are managed appropriately, including external reviews, it required.

Periodically review the design and performance of the incident management and investigation system. The governing body should consider whether it complies with best-practice design principles, and whether enough resources have been allocated to support effective clinical governance and risk management.

The workforce and consumers can be involved in the review of clinical incidents through:

• Regular review of reports or data analysis on clinical incidents
• Periodic review of incident management and investigation systems to ensure that they are effective in improving safety.

Examples of evidence

Select only examples currently in use:

• Incident management and investigation system in which clinical incidents are documented, analysed and reviewed
• Policy documents for reporting, investigating and managing clinical incidents
• Information on clinical incidents, adverse events and near misses, and the actions taken to manage identified risks that are incorporated into the health service organisation’s risk management system or quality improvement plan
• Training documents on recognising, reporting, investigating and analysing incidents, adverse events and near misses
• Committee and meeting records that describe the incident management and investigation system, and the strategies and actions to reduce risk
• Committee and meeting records that show workforce and consumer involvement in the analysis of organisational safety and quality performance data
• Clinical incident reporting forms and tools that are accessible to the workforce and consumers
• Information and resources that support the workforce and consumers to report clinical incidents
• Feedback from the workforce and consumers regarding their involvement in the review and analysis of organisational safety and quality performance data
• Examples of specific improvement activities that have been implemented and evaluated to reduce the risk of incidents identified through the incident management and investigation system
• Results of completed clinical incident investigations
• Audit results of compliance with the incident management and investigation system.

Incident reporting can improve safety (especially when it is based on a cycle of quality improvement), improve care processes, change the way clinicians think about risk and raise awareness of good practice. The nature of the risks faced by organisations varies according to the type of organisation and the context of service delivery. This highlights the importance of evaluating the effectiveness of incident management and investigation systems at the local level.¹

Review the incident management and investigation system

A well-designed incident management and investigation system should support the workforce to identify, report, manage and learn from incidents. The system should comply with legislative requirements and with state or territory clinical incident management policies.

A well-structured system would generally incorporate the following elements:

• A clear policy framework that defines the key elements of the system; the roles and responsibilities of individuals and committees; the type of events to be reported; the process for reporting, investigating, analysing and monitoring clinical incidents; and the responsibility of clinicians to report incidents they observe or that arise from the use of healthcare records, including digital healthcare records
• A focus on managing each incident appropriately from a clinical perspective and ensuring the provision of safe, high-quality care to the patient following the incident, including open disclosure, if appropriate
• A designated individual with responsibility for maintaining the integrity of the system and coordinating incident management
• Adequate and appropriate systems (including relevant equipment and technology) to support incident reporting and analysis
• Workforce responsibilities for managing reported incidents, including grading their severity and leading further investigations
• Policies, procedures and protocols regarding confidentiality of information and the ability of members of the workforce to report anonymously
• Responsibilities for analysing incident data, and identifying trends and opportunities for improvement
• Responsibilities for disseminating information about incidents and their quality improvement implications
• Responsibilities for following up incidents to ensure that improvements have been made, if appropriate; this may include ensuring that information about relevant incidents is incorporated into the organisation’s risk management processes
• Responsibilities for reporting incidents to other parties (for example, health departments) according to relevant organisational obligations
• Links to the organisation’s open disclosure, risk management, and credentialing and scope of clinical practice systems; the state or territory incident management and investigation system, if applicable; and the procedure for communicating with the organisation’s professional indemnity insurers.

Support the workforce

Leaders, including clinical leaders, should encourage the workforce to use the incident management and investigation system to report clinical incidents, near misses and adverse events.

Engaging the workforce to find solutions to issues is important for improving safety¹, especially when the improvement actions require coordination across teams or departments.

Support patients, carers and families

Support patients, carers and families to communicate their concerns by:

• Distributing information to patients and carers about what incidents and concerns are, and how to report them
• Training the workforce on how to respond to patients or carers who raise concerns or report incidents
• Providing, when possible, appropriately skilled members of the workforce to liaise with patients or carers who report concerns or incidents
• Conducting patient experience surveys or seeking feedback on safety incidents on discharge
• Providing information about improvement activities that have been implemented based on patient feedback.

Report on, and review, incidents

Provide comprehensive information to the governing body and management on all serious incidents, and summary information about all other incidents. Include information such as the actions taken as a result of a specific incident or category of incidents, and indicators such as time to complete actions stemming from incident reports. This will enable governing bodies and management to fulfil their governance responsibilities.

Ensure that each incident is reviewed by the clinicians involved and the manager responsible for the operational area in which the incident occurred. This enables lessons to be learned and local improvements to be implemented. A system to verify that managers follow up incidents appropriately will ensure integrity of the risk management system.

Set up classification and escalation processes to ensure that serious incidents, and incidents associated with major risks are managed appropriately, including external reviews, if required.

Periodically review the design and performance of the incident management and investigation system. The governing body should consider whether it complies with best-practice design principles, and whether enough resources have been allocated to support effective clinical governance and risk management.

Examples of evidence

Select only examples currently in use:

• Incident management and investigation system in which clinical incidents are documented, analysed and reviewed
• Policy documents for reporting, investigating and managing clinical incidents
• Information on clinical incidents, adverse events and near misses, and the actions taken to manage identified risks that are incorporated into the health service organisation’s risk management system or quality improvement plan
• Training documents on recognising, reporting, investigating and analysing incidents, adverse events and near misses
• Committee and meeting records that describe the incident management and investigation system, and the strategies and actions to reduce risk
• Committee and meeting records that show workforce and consumer involvement in the analysis of organisational safety and quality performance data
• Clinical incident reporting forms and tools that are accessible to the workforce and consumers
• Information and resources that support the workforce and consumers to report clinical incidents
• Feedback from the workforce and consumers regarding their involvement in the review and analysis of organisational safety and quality performance data
• Examples of specific improvement activities that have been implemented and evaluated to reduce the risk of incidents identified through the incident management and investigation system
• Results of completed clinical incident investigations
• Audit results of compliance with the incident management and investigation system.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt the established incident management and investigation system.

Small hospitals that are not part of a local health network should develop or adapt an incident management and investigation system, and ensure that it:

• Complies with state or territory requirements
• Is appropriately designed, resourced, maintained and monitored
• Clearly designates responsibility for maintaining the system
• Manages each incident from a clinical perspective.

Organisations should have a clear policy framework that defines the key elements of the system, and the roles and responsibilities of individuals and committees. The framework should describe the type of events to be reported, and the process for reporting, investigating, analysing and monitoring clinical incidents. It should also include the responsibility of clinicians to report incidents they observe or that arise from the use of healthcare records, including digital healthcare records.

Organisations need to ensure that:

• The workforce is trained in the assessment and use of the risk management system
• Patients are informed about and supported to report risks or concerns
• A reporting and management framework is implemented to routinely report incident data to the governing body, the workforce and consumers, and to drive improvements in safety and quality
• The incident management and investigation system is periodically audited to improve its design and performance, and to determine if it is adequately resourced
• Processes are in place to ensure the confidentiality of information and the ability of the workforce to report anonymously
• Analysis of incident data is used to identify trends and opportunities for improvement, and is disseminated to the workforce and consumers
• The incident management and investigation system is linked to the organisation’s open disclosure, risk management, credentialing and scope of clinical practice processes; the state or territory incident management and investigation system, if applicable; and the procedure for communicating with the organisation’s professional indemnity insurers.

Examples of evidence

Select only examples currently in use:

• Incident management and investigation system in which clinical incidents are documented, analysed and reviewed
• Policy documents for reporting, investigating and managing clinical incidents
• Information on clinical incidents, adverse events and near misses, and the actions taken to manage identified risks that are incorporated into the health service organisation’s risk management system or quality improvement plan
• Training documents on recognising, reporting, investigating and analysing incidents, adverse events and near misses
• Committee and meeting records that describe the incident management and investigation system, and the strategies and actions to reduce risk
• Committee and meeting records that show workforce and consumer involvement in the analysis of organisational safety and quality performance data
• Clinical incident reporting forms and tools that are accessible to the workforce and consumers
• Information and resources that support the workforce and consumers to report clinical incidents
• Feedback from the workforce and consumers regarding their involvement in the review and analysis of organisational safety and quality performance data
• Examples of specific improvement activities that have been implemented and evaluated to reduce the risk of incidents identified through the incident management and investigation system
• Results of completed clinical incident investigations
• Audit results of compliance with the incident management and investigation system.