Clinical incident management guideline

Guideline number: QH-HSDGDL-032-2:2013

Effective date: 31 January 2021

Review date: 31 January 2024

Supersedes: Version 1.0

On this page:

  1. Purpose
  2. Scope
  3. Guideline for clinical incident management
  4. Supporting and related documents
  5. Definition of terms
  6. Approval and implementation
  7. Version control

1. Purpose

This Guideline provides recommendations regarding best practice for clinical incident management.

2. Scope

This Guideline applies to Queensland Health employees, agents, volunteers, contractors, consultants and managed service providers working for the Divisions within the Department of Health, Agencies and Business Units and for the Hospital and Health Services (including Visiting Medical Officers).

3. Guideline for clinical incident management

Clinical incidents can and do occur in the course of providing healthcare. By recording, analysing and learning from these clinical incidents, both at the Hospital and Health Service level and at the state-wide level, future clinical incidents and patient harm may be minimised.

The Patient Safety and Quality Improvement Service (PSQIS), Clinical Excellence Queensland (CEQ), Department of Health, provides various resources to help support Iearnings and quality improvement in response to patient safety incidents. The Queensland Health Best Practice Guide to Clinical Incident Management, factsheets, forms and other resources are available on QHEPS. Clinical Incident Analysis interactive online modules are also available on ilearn.

PSQIS also reviews clinical incident analysis reports from both the Queensland public health system and the coronial system. Trends relating to patient safety issues are analysed and the results are used to inform statewide patient safety initiatives and are shared with Hospital and Health Services to help reduce the potential for preventable patient harm.

3.1 Incident reporting

3.1.1 Hospital and Health Services should have an established local documented process for identifying, managing and reporting any clinical incident which has resulted in actual or potential patient harm.

3.1.2 This process should include specific roles and responsibilities for recording all clinical incidents in Queensland Health’s RiskMan information system as soon as practicable after the incident has occurred. Severity assessment code 1 (SAC1) clinical incidents should be reported to the Department of Health through RiskMan within one (1) business day of a service becoming aware of the incident.

3.1.3 The local clinical incident processes should also include, or link to, a process for identifying and managing patient safety issues/risks (refer to: Guideline for Patient Safety Notification System QH-HSDGDL-032-4).

3.1.4 Hospital and Health Services should have a local process for directly notifying significant clinical incidents to the Director-General, Queensland Health. If there is a question about notifying the Director-General, this can be discussed with the
Senior Departmental Liaison Officer by email: SDLO@health.qld.gov.au.

3.2 Incident analysis

3.2.1 Hospital and Health Services should have an established local documented process for incident analysis and should include incidents that will be subject to analysis, the method of analysis and the roles and responsibilities for those involved with the incident analysis process.

3.2.2 This process should include timeframes for the completion of incident analysis. At a minimum, and as required by the Patient Safety Health Service Directive, SAC1 incidents should undergo incident analysis within 90 calendar days of the incident being reported.

3.2.3 The process should include a specific role responsibility to submit the SAC1 analysis report to the PSQIS. As required by the Patient Safety Health Service Directive, the SAC1 analysis report should be submitted within 90 calendar days of the incident being reported. Where a SAC1 analysis report cannot be submitted within 90 calendar days of the incident being reported, an email should be sent to PSQIS advising of the reason for the delay and the anticipated completion date.

3.2.4 A SAC1 analysis report must contain:

  • A factual description of the event
  • The factors identified as having contributed to the event
  • Recommendations to prevent or reduce the likelihood of a similar event happening again.

  • PSQIS contact details for SAC1 incident analysis reports:
    Phone: 3328 9430
    Email: PSQ-SAC1DOCUMENTS@health.qld.gov.au

3.3 Development and implementation of recommendations

3.3.1 Hospital and Health Services should have an established local documented process for the development of recommendations arising from SAC1 analysis, that should include engaging with relevant stakeholders and prioritising recommendations based on impact and achievability.

3.3.2 Hospital and Health Services should have an established local documented process for the testing (if necessary) and the implementation of recommendations. This process should include timelines for implementation and data collection to demonstrate both implementation and sustaining of the recommendations.

3.4 Coronial recommendation management

3.4.1 There is no requirement for a Hospital and Health Service to accept and implement a coronial recommendation. However, there is a requirement to contribute to whole-of-government public reporting on any government response to a coronial recommendation.

3.4.2 Hospital and Health Services should have an established local process for recording, considering and actioning recommendations made by a Coroner to the Hospital and Health Service following a coronial inquest.

3.4.3 The process should include a documented decision-making approach for each recommendation. When a recommendation is accepted, a plan for implementing and monitoring the recommendation should also be documented.

3.4.4 The process should also include a specific role responsibility for submitting an initial response to a coronial recommendation to PSQIS, as required by the Patient Safety Health Service Directive. This response should be submitted by email on the Department’s coronial response template within 90 days of the inquest findings being delivered.

3.4.5 Updates are required to be provided six monthly until the implementation of the recommendation/s is complete.

3.4.6 Coronial response reporting instructions and templates are available on QHEPS.

PSQIS contact details for coronial management:
Phone: 3328 9430
Email: psccoronial@health.qld.gov.au

4. Supporting and related documents

Authorising Health Service Directive

Related guidelines

Patient Safety Notification System guideline QH-HSDGDL-033-3:2014

Legislation

  • Hospital and Health Boards Act 2011
  • Hospital and Health Boards Regulation 2012

Resources

Accreditation references

5. Definition of terms used in this directive

Term Definition / explanation / detailsSource

Clinical incident

Any event or circumstance which has actually or could potentially lead to unintended and/or unnecessary mental or physical harm to a patient

Queensland Health Clinical Incident Management Guideline

Severity assessment code (SAC) 1

Death or likely permanent harm which is not reasonably expected as an outcome of health care.

Queensland Health Clinical Incident Management Guideline

6. Approval and implementation

Guideline custodian

Executive Director, PSQIS, Clinical Excellence Queensland

Approving officer

Deputy Director General, Clinical Excellence Queensland, Department of Health

Approval date: 20/01/2021

Effective from: 31/01/2021

7. Version control

VersionDate Prepared byComments
1.0 01/08/2013 HSCI New Guideline
2.0 31/01/2021 PSQIS

Updated email addresses, phone numbers and the name Patient Safety Unit, to Patient Safety and Quality Improvement Service.

Minor clerical amendments in line with the Queensland Health Editorial style guide 2019.

Modified requirement of coronial reporting from quarterly to six monthly.

Added PSQIS role in provision of resources and on-line education.

Last updated: 31 January 2021