Standard Operating Policy

VARIATION TO CLINICAL PRACTICE

CLINICAL REVIEW
Document No.
File No.

SOP2013-003
12/381 (D13/1482)

Date issued

23 January 2013

Contents

Policy Statement

Author Branch
Branch Contact
Division

Variation to clinical practice

Clinical Review

Clinical Governance
Patient Safety
Clinical Governance

Summary

The purpose of this policy is to outline procedures in the event of a Variation to

Clinical Practice and Clinical Review

Applies to

All NSW Ambulance staff including paramedics, patient transport officers, doctors,
nurses, volunteers, and corporate staff

Review Date
Previous Reference
Status
Approved by

15 January 2015
SOP2008-038
Active
Chief Executive

Related Documents

Revision History
Version (Circular #)

Amendment notes

23 January 2013
(SOP2013-003)

Endorsed by Chief Executive

Functional and terminology updates in accordance with management and policy
changes.

12 December 2008
(SOP2008-038)

Final Endorsed by Chief Executive

Compliance with this policy directive is mandatory

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Standard Operating Policy

INTRODUCTION
A Variation to Clinical Practice (VCP) is defined as any clinical intervention undertaken that is not consistent
with current NSW Ambulance protocols, pharmacology, skills or procedures.
Variations occur for a number of reasons, however in all cases it is recommended that they are reported and
measured against the best available evidence as documented in agreed clinical practice guidelines. Variations
include cases where a paramedic decides in the patients best interest, to work outside authorised clinical
practice, protocols, and cases where an inadvertent mistake was made.
A variation does not necessarily equate with an error nor does the reporting of a variation imply permission to
act outside authorised clinical skill levels or to vary practice beyond recommended protocol.
To enable supported Open Disclosure paramedics are required to report the incident to the Duty Operations
Manager (DOM) when an error has occurred. Refer to Figure 1 on page 4.
NSW Ambulance acknowledges that variations will occur on occasion and supports the development of a
culture and environment wherein all clinicians are encouraged to recognise and promote patient safety through
the identification of opportunities to review and improve clinical practice that may arise by reporting these
variations.
The purpose of this policy is to ensure that a just culture prevails in the management of variations, and that
NSW Ambulance provides support for paramedics where a variation or error has occurred.
CLINICAL REVIEW
The primary purpose of a clinical review is to ensure that patients receive care consistent with best practice.
The Clinical Review Group (CRG) reviews all variations with the focus being on the clinical aspects of the
case, with each incident assessed on its own merit. The Clinical Governance Staff Specialist and Manager
Patient Safety jointly chair the CRG. Members of the CRG are bound by a confidentiality clause included
within the Terms of Reference.
Clinical reviews are a quality improvement process that seeks to improve patient care and outcomes through a
systemic review of care against clinical protocols and best practice. Additionally, clinical reviews assist in
identifying trends in clinical practice that inform the development of clinical protocols.

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Standard Operating Policy

INCIDENT REFERRALS
In addition to VCPs, managers can refer incidents to the CRG requesting a determination on clinical aspects of
an incident, which is as a result of a clinical record audit or to support investigations. An incident referred to the
CRG must be accompanied by a briefing note or provide detail on why the incident has been referred for
clinical review.
Note:
Referrals to the CRG must include supporting documentation e.g. clinical record/s and initial fact finding notes.

THE REPORTING PROCESS

Variations are reported via the IIMS reporting process. Refer to Figure 1 on page 4.
Although reports can be made anonymously, it is preferable to provide a notifier as it enables
feedback to be provided.
The Clinical Risk Advice Line provides advice to paramedics about the administrative processes to be followed
in the event of a variation rather than advice on the clinical management of a patient they are treating.

OUTCOME OF REVIEWS
The CRG will write to the notifier advising of the review outcome with specific feedback according to the type
of variation and any associated support recommendations.
To maintain confidentiality, the review findings are conveyed only to the notifier, irrespective of whether the
case is self-reported or reported by another party.

CLINICAL GOVERNANCE
The CRG provides a de-identified report detailing the categorisation of variations, associated trends and
recommended actions to the Clinical Governance Committee through the Executive Director Clinical
Governance.
For more information or if you have any questions regarding the variation to clinical practice process or
reporting variations contact the Patient Safety Manager on 9779 3824 or email your comments to
ClinicalReview@ambulance.nsw.gov.au.

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Standard Operating Policy

FIG 1: VCP Process Flow Chart

Have you performed a Variation to Clinical

Practice (VCP)?

Yes

Was it an error?
Yes

Open Disclosure required

To enable Open Disclosure in a
supported environment, paramedics
are required to Notify the DOM on
duty.
For additional support paramedics
can also contact either;

Or

The Clinical Risk Advice

Line* 0428 238 423;

Email
clinical@ambulance.nsw.gov.au

Or

Notify your Clinical Training

Officer, Regional Educator
or Local Manager who will
contact the Clinical Risk
Advice Line on your behalf

*Clinical Risk Advice Line provides paramedics with

clarification to whether a variation has occurred and
advice in the administrative process of reporting a VCP

No

Documentation
Complete an IIMS, (IIMS is located on
the ASNSW intranet home page) using
the Clinical subgroup within the Incident
Notification Category. Once the IIMS has
opened select Variation to Clinical
Practice within the Incident
Monitoring>Australia>New South Wales
subgroup

Ensure all relevant information is included on the IIMS

such as; case number, eMR number, patient name,
incident date and location. If you are still using a PHCR
you will need to record the IIMS number on the PHCR
and forward to the Patient Safety Officer. This allows
Patient Safety to accurately identify the corresponding
clinical record for review

What happens to your VCP?

Review
All VCPs are reviewed by the Clinical Review
Group (CRG) who assess each VCP on its
own merit taking into account improvements
in patient safety and clinical quality

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