Significant Incident SOP



ProcedureSignificant IncidentsPurposeThe 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 CommunicationFeedback 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.DocumentationAll 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: IdentificationSignificant incidents may be identified by anyone and can be summarised as those that meet the criteria for a: Extreme incidentMajor incident, orHigh risk incident.A. EXTREME INCIDENTS:CategoryIncident or event resulting in:PeopleDeath of a worker*/visitor following a workplace incident ClinicalPatient death unrelated to the natural course of the underlying illness and/or differing from the immediate expected outcome of patient managementDeath 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 & ServicesLoss of an essential service resulting in shutdown of a service unit or facilityDisaster plan activation Destruction or damage to property requiring significant unbudgeted expenditureFinancialLoss of 25% of budget or between $200M- $500MInformationComplete permanent loss of all Health Directorate or divisional/service records and dataBusiness Process & SystemsCritical system failure, bad policy advice or on-going non-compliance. Business severely affected. ReputationClaims made by the media that have an extreme impact on community perception of the organizationEnvironmentToxic 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:CategoryIncident or event resulting in:PeopleA hostage situation.Three or more workers requiring time off following an adverse event in the workplaceClinicalMajor 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 ServicesMajor damage to one or more services or departments affecting the whole facility – unable to be managed by alternative routine proceduresService 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 expenditureFinancialLoss of 10% of budget or between $10M - 200MInformation Complete, permanent loss of some Health Directorate or Division/ Business Unit/Service records and/or data, or loss of access greater than 1 weekInappropriate 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 workerBusiness Process & SystemsStrategies not consistent with Health Directorate and Governments agenda. Trends show service is degraded.ReputationClaims made by the media that have a major impact on community perception of the organisationEnvironmentToxic release (i.e. chemical, biological, radiological) requiring assistance of emergency services with no detrimental effect)C. HIGH RISK INCIDENTSA 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; orPossible significant incidents; (that is, significant incident status is unclear until further review is conducted)Incidents Notifiable to Work Safe ACT. These include: 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; orImmediate treatment for the amputation of any part of his or her body; ora serious head injury; or a serious eye injury; ora serious burn; orthe separation of his or her skin from an underlying tissue (such as degloving or scalping); ora spinal injury; orthe loss of bodily function; orserious lacerations; orMedical treatment within 48 hrs of exposure to a substanceA 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: . 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: ClassificationStaff 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/orNot being in line with the definition of a significant incidentThese incidents will be downgraded from the Significant Incident status. Changes in status will be communicated back to the relevant Executive Director.Step 4: InvestigationAll 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: ActionActions 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: EvaluationWhen 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 addressedrecurrences have been reduced or eliminatedlessons have been learned and communicatedidentified barriers to change have been removedthe loop is closed to ensure organisational learningA number of strategies can be used to evaluate the implementation, including a risk assessment and monitoring of incident data for similar incidents.EvaluationOutcome MeasuresInitial 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.MethodThe HCID monitor internally and escalates as appropriate.Related Legislation, Policies and Standards LegislationHealth Act 1993 (ACT). Human Rights Act 2004 (ACT)Freedom of Information Act 1989 Safety Rehabilitation and Compensation Act 1988Work Health and Safety Act 2011 Work Health and Safety Regulation 2011Public Interest Disclosure Act 1994 (ACT) Work Health and Safety Codes of PracticeStandards ACHS EQuIP 5, Support, Criteria 2.1.2 & 2.1.3 Australian Commission on Safety and Quality in Healthcare – National Safety and Quality Health Service StandardsOpen Disclosure Standard: a National Standard for Open Communication in Public and Private Hospitals, Following an Adverse Event in Health Care 2003 (under review)Risk Management Standard (ISO 31000:2009)Australian Charter of Healthcare RightsPolicies and Standard Operating Procedures (SOPs) Health Directorate “Incident Management” ProcedureHealth Directorate “Significant Incidents” Procedure Health Directorate “Open Disclosure” Procedure Health Directorate “Look Back” Procedure Health Directorate “Consumer Feedback Management” PolicyHealth Directorate “Risk Management” Policy, Procedure and Guidelines (under review)ACT Health Clinical Review Process Framework (2008) (under review)Little Company of Mary Health Care, Significant Events Policy Little Company of Mary Health Care, Clinical Governance Framework Little Company of Mary Health Care. Incident, Accident and Near Miss Health Directorate Records Management PolicyEmployees Assistance Program PolicyPreventing and Managing Aggression and Violence PolicyHealth Directorate Public Interest Disclosure Policy (under review)Mental Health, Justice Health and Alcohol and Drug Services policy: “Incidents Reportable to the Director of Mental Health” (under review)Health Directorate Safety Management System (under review)Definition of Terms (only use this section if needed, delete if not needed)Adverse eventan incident in which harm resulted to a person receiving health care.Dangerous incidentany 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 substancean uncontrolled implosion, explosion or firean uncontrolled escape of gas or steaman uncontrolled escape of a pressurised substanceelectric shockthe fall or release from a height of any plant*, substance or thingthe collapse, overturning, failure or malfunction of, or damage to any plant that is required to be authorised for use in the regulationsthe collapse or partial collapse of a structurethe collapse or failure of an evacuation or of any shoring supporting an excavationthe inrush of water, mud or gas in workings, in an underground excavation or tunnelthe interuption of the main system of ventilation in an underground excavation or tunnel oranother event prescribed in the regulations.A dangerous incident can also be referred to as a Significant Incident and/or a Notifiable Incident. *See definition of “plant” below.Hazarda circumstance or agent that can lead to harm, damage or loss (includes within a consumers home) High risk incidentany event that would have resulted in a significant incident should it have eventuated (also referred to as a significant near miss), incidents that could attract significant media attention and possible significant incidents where the status is unclear until further investigation is undertaken.IncidentAn event or circumstance which could have resulted in, or did result, in unintended or unnecessary:harm to a workerto a patient/client/consumer complaint, loss or damage to property and services (including infrastructure)to the environmentregarding financial managementregarding information managementregarding the reputation of the organisationdeviationsfrom endorsed plans/processes.Look Backa standardised process that is triggered when a notification of a clinical incident, or concern, from any source leads to the need for the notification, investigation and the management of a group of commonly affected consumers. The clinical incident may arise from complications or errors relating to diagnostics, treatment or products that consumers have received.Near missAn incident that did not cause harmNotifiable incident (staff)an incident which occurs to a staff member and requires immediate notification to the Workplace Safety Section of the Quality and Safety Unit and WorkSafe ACT. It includes:The death of a staff member orA serious injury or illness of a staff member orA dangerous incident (also see definition)A notifiable incident can also be referred to as a Significant Incident.Open disclosureis a process of communication with consumers following an adverse event and is not a legal process. Apologising and disclosing an adverse event to a consumer is not the same as admitting fault, rather it is an expression of regret and statements of fact. The standard outlines a clear and consistent process which includes:an apologyan invitation for the consumer to relay their perspective on the eventa factual explanation of what occurred, including actual and potential consequences, andthe steps being taken to manage the event and prevent its recurrenceRefer to the Open Disclosure Procedure for more information.Outcome ratingsee Appendix A of the Incident Management ProcedurePlant (related to a dangerous incident)Includes any machinery, equipment, appliance, container, implement and tool or anything fitted or connected to machinery, equipment, appliance, container, implement or a tool.RiskmanAn online web based system used to report incidentsSentinel eventsThe Australian Commission for Safety and Quality in Health Care has worked closely with all jurisdictions to develop a national core set of sentinel events. The agreed national list of core sentinel events consists of: Procedures involving the wrong patient or body part resulting in death or permanent loss of functionSuicide of a patient in an inpatient unit Retained instruments or other material after surgery requiring re-operation or further surgical procedure Intravascular gas embolism resulting in death or neurological damage Haemolytic blood transfusion reaction resulting from ABO incompatibility Medication error leading to the death of patient reasonably believed to be due to incorrect administration of drugs Maternal death or serious morbidity associated with labour or delivery Infant discharged to the wrong family.A sentinel event can also be referred to as a Significant Incident.Significant Incidentan incident with an Extreme or Major outcome occurring in relation to Health Directorate services and care, requiring immediate notification to the Director General/Deputy Director General. Significant Incidents include Sentinel events and Notifiable Incidents.Work Injuryan injury or illness contracted as a result of duties performed during the course or work activities.ReferencesAustralian Commission on Safety and Quality in Healthcare 2008; National Safety and Quality Health Service Standards, Commonwealth of Australia.NSW Health 2007, Incident Management Policy Directive, Department of Health, NSW.Queensland Health 2009, Clinical Incident Management Implementation Standard (CIMIS), Queensland Government, ernment of Western Australia Department of Health 2011; Clinical Incident Management Policy; Western Australian Department of Health, Western Australia.AttachmentsAttachment A – Reporting Requirements Flow ChartAttachment B – Reporting Requirements TableDisclaimer: This document has been developed by Health Directorate, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.12. Final report submitted by Exec Dir/ CEO (Calvary).Open Disclosure meeting convened as appropriate11. QSU/ Calvary QSR/Corporate delegate prepares a final report taken from the review findings and forwards to relevant Exec Dir/ CEO (Calvary)Attachment A3. Exec Dir/ CEO (Calvary) report the incident verbally to Health Directorate DG/DDG Open Disclosure discussion commencesMinisterial briefing process commences as per Exec Coord processes10. Interim report submitted by Exec Dir/ CEO CalvaryOpen Disclosure meeting as appropriate9. QSU/ Calvary QSR/Corporate delegate prepares an interim report and forwards to relevant Exec Dir/CEO (Calvary)1. Staff member identifies incident and reports verbally to Manager. Incident notified through Riskman. Day 1008. Incident review undertaken by QSU CRC/ QSR Calvary/ relevant corporate area.Day 45Within 24 hoursWithin 12 hours7. Relevant Exec Dir/CEO (Calvary) approves the SIB for submission.Notification to ACTIA within 10 days6. QSU/ Calvary QSR/ Corporate delegate sends the SIB to the Exec Dir/ CEO (Calvary)5. QSU/ Calvary QSR/ Corporate delegate gather information from relevant staff and complete the SIB within 24 hoursReporting Requirements Flow Chart4. Exec Dir/ CEO (Calvary) liaises with relevant staff (i.e.QSU/Calvary QSR/ Corporate delegate) to rate the incident & prepare a Significant Incident Brief (SIB)2. Manager reviews the incident. If extreme or major, reports directly to senior management Exec Dir/ CEO (Calvary)Note: The Workplace Safety Section, QSU and WorkSafe ACT must be made aware immediately of Notifiable Incidents. Reporting RequirementsSignificant Incident12 hours:Within 12 hours of the incident, a verbal report will be provided to the relevant Executive Director and by the Executive Director/CEO Calvary or their delegate to the Director General/Deputy Director General.Note: The Workplace Safety Section, QSU and WorkSafe ACT must be made aware immediately of Notifiable IncidentsTelephone Initial report Day 1: An electronic incident report identifying incident details and status will be submitted. The Clinical Risk Coordinator/Workplace Safety Advisors /QSR staff Calvary will prepare the Significant Incident Brief which is then cleared by the relevant Executive Director/CEO Calvary, and distributed to the Director General and Deputy Director General within 1 working day of staff identifying the incident.Significant Incident Initial Report(Riskman)Interim Report Day 45 - By exception only:Within 45 calendar days of incident notification, an Interim SIB report outlining a progress update, any changes to outcome status and details of any investigation being conducted will be provided to the Director General and Deputy Director General. Significant Incident Interim Report (Riskman)Final Report Day 100:Within 100 calendar days of incident notification, a final SIB report will be submitted. The relevant recommendations identified from the review are agreed, endorsed, monitored and managed by the peak Quality/Risk Management meeting/Calvary Quality, Safety & Risk Unit and relevant Corporate processesSignificant Incident Final Report(Riskman)Attachment BNote: The timeframes provided are internal deadlines. Communication with the consumer should occur via an open disclosure process as information arises. ................
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