DGD12-047

Standard Operating Procedure

Incident Management
Purpose

The incident management system provides a step by step process for staf
to follow when an incident occurs. All staf are expected to participate in
the incident management process and undertake training as relevant to
their position.

Scope

This procedure applies to all staf of the Health Directorate, including

contractors.

Procedure

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 1 of 16
2012 2015
DGD12-047

Two factors which relate to the entire incident management process are as
follows:

Feedback and Communication

Feedback and communication of an incident relates to the entire process

and is an important mechanism to improve processes and prevent
recurrence.

The success of incident management is dependent on communication to

all staf during the process in a timely manner. Staf involved in an incident
need to be informed of the recommendations arising from any
investigation. These may be presented by their manager/supervisor at
staf meetings or via the Quality and Safety Officers at Divisional Quality
and Safety or Clinical Governance committees.

Generally, major and extreme outcome rated incidents will require a

formal open disclosure process. Incidents which are rated moderate or
below require open communication using the principles of open disclosure.
The type of response is flexible and determined on a case-by-case basis.
Please refer to the Significant Incident and Open Disclosure SOPs for more
information.

Documentation

Each step of the incident management process should be documented in

the Riskman incident notification and reporting module (Riskman).
Documentation in Riskman should be in the same manner as the Clinical
Record. This provides a complete picture of what happened and what was
done to prevent the incident occurring again. For incidents involving
consumers, the incident should also be documented in the medical record
with the corresponding Riskman identification number. Managers are
responsible for reviewing, adding journal entries and finalising incidents
reported by their staf in a timely manner.

Step 1: Identification

Staf who may identify an incident need to consider the following:

 The type of incident, e.g. worker injury, significant incident, harm
to a consumer, incidents reportable to Executive Director of
Mental Health, Justice Health and Alcohol and Drug Services.
 The immediate action required. This may include
i. providing immediate care to individuals involved
ii. making a situation/scene safe to prevent recurrence
iii. managing malfunctioning equipment
iv. gathering basic information to include in the Riskman report
v. notifying supervisors/managers or security or the police
vi. apologising to the people involved if the incident is a result
of treatment or systems error - see Open Disclosure SOP for
more information.
Doc Issued Review Area Page
Number Date Responsible
DGD12-047 October October QSU 2 of 16
2012 2015
DGD12-047

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 3 of 16
2012 2015
DGD12-047
Step 2: Notification

All incidents should be lodged in Riskman and documented in the clinical

record. Incidents should be lodged by 11.59pm the day following the
incident. This includes near misses and high risk incidents, even where
there is no obvious outcome.

Note: If staf do not have access to Riskman, a telephone call can be

made to the Riskman Help Desk on Ph: (02) 6205 4000.

All identified hazards that have the potential to cause injury or illness to
others should be notified as “non-individual” incidents on Riskman.

Step 3: Classification

Incidents are initially classified by the reporter of the incident according to

the severity of the outcome, which is noted in the electronic Riskman
report form. Attachment A outlines how to rate incidents using categories,
i.e., people, clinical (i.e. consumers), environment, property and services,
financial, information technology issues, business processes, reputation
and the environment. Under each category, examples are given to assist
with the rating process.

All incidents that are outcome rated Major or Extreme will require
escalation. Significant incidents require immediate senior clinical and
executive notification and attention to ensure that they are managed
appropriately. Please refer to the Significant Incident SOP for more
information. If the incident is a result of a treatment or systems error or an
unexpected change in care, please refer to the Open Disclosure SOP.

Once an incident is lodged into Riskman by staf, Incident Classifiers may

amend outcome ratings and contributing factors as required and will
review content for completeness and accuracy. When an incident requires
action from staf outside the notification source, the classifiers will
distribute appropriately. Incident Classifiers also provide Helpdesk support
to staf using Riskman to notify incidents (Ph: (02) 6205 4000).

Step 4: Investigation

Investigation methods of incidents may include aggregated data analysis,

risk assessments, interviews with staf/consumers/family members, review
of policies and procedures and clinical record reviews. The investigation
method chosen should be determined by outcome and the complexity of
the incident.

The details of the investigation are to be entered into the Riskman incident
reporting and notification module by the appropriate staf member.

All staf incidents require appropriate recommendations and are tabled at

the appropriate committee, with reports to the Executive Directors every
three months.
Doc Issued Review Area Page
Number Date Responsible
DGD12-047 October October QSU 4 of 16
2012 2015
DGD12-047

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 5 of 16
2012 2015
DGD12-047
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

Recommendations arising from incidents are to be implemented within an

agreed timeframe following the finalised investigation. When all
recommendations are implemented and given time to imbed into practice,
the local area should evaluate the efectiveness 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
 systems are in place to ensure organisational learning.

A number of strategies can be used to evaluate the implementation,

including a risk assessment, monitoring of incident data for similar
incidents and a “Look Back” process.

Special Circumstances

Incidents attracting media attention

Guidelines for what to do if approached by the media regarding an incident
can be found in the Health Directorate Media Policy.

Interagency incidents
Clinical incidents that involve both the care managed by the Health
Directorate and by other external agencies, including the ACT Ambulance
Service and NSW Southern Local Health District/Murrumbidgee Local
Health District, will be referred to the Health Directorate Health
Interagency Clinical Review Committee (HICRC) for investigation. HICRC
has developed guidelines for the identification, reporting, notification and
investigation of inter-agency clinical significant incidents.

Requests for Release of Information

Incident reports pertaining to consumers may be required to be disclosed
to third parties. For example, under the Civil Law (Wrongs) Act 2002 where
a claim for damages for personal injury is made, or under the discovery
process where litigation has been commenced, the consumer and their
legal representative are entitled to receive documents which are relevant.
Documents such as clinical records and incident reports would be relevant
and accordingly may need to be provided. Similarly, incident reports are
released under the Freedom of Information Act 1982.

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 6 of 16
2012 2015
DGD12-047
Any request for health records by patients/clients/consumers or third
parties made through the Medical Records Department or the Release of
Information Coordinator in Mental Health, Justice Health and Alcohol and
Drug Services (MH, JH and ADS) activate release of corresponding incident
notifications. This is done in line with the Release of Riskman Incident
Notifications SOP.

Calvary Health Care ACT

The governance arrangements in the Health Directorate are such that staf
working in the Mental Health, Justice Health and Alcohol and Drugs Service
(MH, JH and ADS), Pathology Division and Business and Infrastructure
Branch may be working on the Calvary campus although have reporting
responsibilities to their respective division/branch. Any incident reported
on the Calvary campus is reviewed and investigated by staf from the
Calvary Quality, Safety & Risk Unit (QSR). Processes exist between the
Quality and Safety Unit and the Quality, Safety and Risk (QSR) Unit to
facilitate reporting of Significant Incidents occurring on the Calvary
campus through Riskman and to notify each other of incidents involving
both organisations.

Note: The Brian Hennessy Rehabilitation Centre (BHRC), whilst in close

vicinity to the Calvary site is not part of the Calvary Campus. Incidents
from BHRC are reviewed and investigated by the Division of MH, JH and
ADS. The Older Persons Mental Health Inpatient Unit (OPMHIU) does
however report through Calvary Health Care, therefore incidents are
reviewed and investigated by the QSR Unit, Calvary.

Evaluation

Outcome Measures
 100% of staf incidents have documented evidence of
investigation in the Riskman system and controls implemented 5
days post incident notification date.
 100% of incidents are notified by 11.59pm the day following the
incident.
NB: Significant incident timeframes still apply as per the
Significant Incidents SOP.

Method
 Reports are generated from Riskman and reported at the Work
Health and Safety Committee and the Divisional Quality and
Safety Committees respectively.

Related Legislation, Policies and Standards

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
Doc Issued Review Area Page
Number Date Responsible
DGD12-047 October October QSU 7 of 16
2012 2015
DGD12-047
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

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 8 of 16
2012 2015
DGD12-047
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
o Health Directorate “Consumer Feedback Management” Policy and
SOP
o Health Directorate “Risk Management Policy”, Standard Operating
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)

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 9 of 16
2012 2015
DGD12-047
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 any incident in relation to a workplace that exposes a

incident 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
 the collapse or failure of an evacuation or of any
shoring supporting an excavation
 the inrush of water, mud or gas in workings, in an
underground excavation or tunnel
 the interruption of the main system of ventilation in
an underground excavation or tunnel or
 another 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.

Hazard a circumstance or agent that can lead to harm, damage

or loss.

High risk any event that would have resulted in a significant

incident 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.

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 10 of 16
2012 2015
DGD12-047
Incident An event or circumstance which could have resulted in,
or did result, in unintended or unnecessary:
 harm
o to a worker
o to a patient/client/consumer
 complaint, loss or damage
o to property and services (including
infrastructure)
o to the environment
o regarding financial management
o regarding information management
o regarding the reputation of the organisation
 deviations
o from endorsed plans/processes.

Look Back a 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 afected consumers. The clinical incident
may arise from complications or errors relating to
diagnostics, treatment or products that consumers have
received.

Near miss An incident that did not cause harm

Notifiable an incident which occurs to a staf member and requires

incident (staf) immediate notification to the Workplace Safety Section
of the Quality and Safety Unit and WorkSafe ACT. It
includes:
a) The death of a staf member or
b) A serious injury or illness of a staf member or
c) A dangerous incident (also see definition)
A notifiable incident can also be referred to as a
Significant Incident.

Open is a process of communication with consumers following

disclosure 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 apology
 an invitation for the consumer to relay their
perspective on the event
 a factual explanation of what occurred, including
actual and potential consequences, and
 the steps being taken to manage the event and
prevent its recurrence
Refer to the Open Disclosure SOP for more information.
Doc Issued Review Area Page
Number Date Responsible
DGD12-047 October October QSU 11 of 16
2012 2015
DGD12-047

Outcome see Appendix A of the Incident Management SOP

rating
Plant (related Includes any machinery, equipment, appliance,
to a container, implement and tool or anything fitted or
dangerous connected to machinery, equipment, appliance,
incident) container, implement or a tool.

Riskman An online web based system used to report incidents

Sentinel The Australian Commission for Safety and Quality in

events 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 function
 Suicide 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 an incident with an Extreme or Major outcome occurring

Incident 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 Injury an injury or illness contracted as a result of duties

performed during the course or work activities.

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 12 of 16
2012 2015
DGD12-047
References

Australian 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, Queensland.

Government of Western Australia Department of Health 2011; Clinical

Incident Management Policy; Western Australian Department of Health,
Western Australia.

Attachments

A – Outcome rating table

B – Incident Management Flowchart

Disclaimer: 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.

Doc Issued Review Area Page

Number Date Responsible
DGD12-047 October October QSU 13 of 16
2012 2015
 DGD12-047

Appendix A
Outcome Rating Table
Insignificant Minor Moderate Major Extreme/Catastrophic
Significant Incident Significant incident

Injuries or First aid Lost time and/or A hostage situation Death of a worker/visitor
ailments related treatment injury to 1 or more following a workplace
to a workplace workers/visitors incident
Three or more staf requiring
People incident not related to a time of following an adverse
(Staf, requiring workplace incident event
Contractors, medical
Visitors, treatment No lost time or Medical expenses or
students) restricted duties restricted duties
related to a related to a
workplace workplace incident
incident
No injury Minor injury Temporary loss of Major and permanent loss of Patient death unrelated to
requiring: function (sensory, function (sensory, motor, the natural course of the
o Review and motor, physiologic physiological or intellectual) underlying illness and
No review
evaluation or intellectual) unrelated to the natural difering from the
required
unrelated to the course of the underlying immediate expected
o Additional
natural course of illness and difering from the outcome of patient
observations the underlying expected outcome of patient management.
No increased
Clinical level of care o First aid illness and difering management.
(patient, client, treatment from the expected
Death of a client in
consumer outcome of patient
# Hysterectomy as an custody (under MH order
related) management.
emergency procedure (e.g. EA, ED3, ED7 or PTO)
following childbirth will be or police custody)
Incident resulting in assessed on a case by case
transfer to higher basis through clinical review All national core
level of care or process for outcome rating. sentinel events (see
additional definition of terms)
procedure.

No loss of Closure or Disruption to one Major damage to one or more Loss of an essential
service disruption of a service or services or departments service resulting in shut
service for less department for 4 to afecting the whole facility – down of a service unit or
than 4 hours- 24 hours - managed unable to be managed by facility
managed by by alternative alternative routine
alternative routine procedures procedures.
routine
procedures.
Disaster plan activation
Cancellation of Service evacuation causing
Event that may Reduced appointments or major disruption of greater
Property and have resulted in efficiency or admissions for a than 24 hours, e.g. Fire/ flood
Services the disruption disruption of number of patients requiring evacuation of
of services but some aspects of workers/visitors and
(Business an essential
did not on this patients/clients (no injury)
services and service.
occasion. Destruction or damage to
continuity)
Cancellation of property requiring
surgery or Bomb threat procedure significant unbudgeted
Minimal or no activation, potential bomb
destruction or procedure more expenditure
Destruction or than twice for one identified, partial or full
damage to damage to evacuation required (+/-
property patient
property injury)
Destruction or
requiring some
damage to property
unbudgeted
requiring minor Destruction or damage of
expenditure
unbudgeted property requiring major
expenditure unbudgeted expenditure

Loss of 1% of Loss of 2.5% of Loss of 5% of Loss of 10% of budget or Loss of 25% of budget or
budget or budget or budget or between between $10M - $200M between $200M - $500M
Financial
<$50K between $50 - $5 -$10M
$1M
Information Interruption to Interruption to Significant Complete, permanent loss of Complete, permanent loss
records / data records / data interruption (but not some ACT Health or of all ACT Health or
access less than access ½ to 1day permanent loss) to Division/Business Unit/Service divisional/service records
½ day data / records records and / or data, or loss and data.
access, lasting 1 of access greater than 1 week.
day to 1 week
Event that may Inappropriate
have resulted in storage of Inappropriate storage or
the mishandling clinical records in Inappropriate exposure of patient/client
of clinical a department storage of clinical consumer or clinical records in
records records in the a public area +/- breach in
facility patient privacy and
confidentiality. (These will be
 DGD12-047

Insignificant Minor Moderate Major Extreme/Catastrophic

Significant Incident Significant incident

assessed on a case by case

basis.)

Inappropriate destruction of
patient/client/consumer
clinical records by a worker
Minor errors in Policy procedural One or more key Strategies not consistent with Critical system failure, bad
systems or rule accountability Health Directorate and policy advice or ongoing
processes occasionally not requirements not Government’s agenda. Trends non-compliance. Business
requiring met or services met. show service is degraded severely afected.
Business corrective do not fully meet Inconvenient but not
Process and action, or minor needs. client welfare
Systems delay without threatening.
impact on
overall
schedule.

Claims made by Claims made by Claims made by the Claims made by the media Claims made by the media
the media that the media that media that have a that have a major impact on that have an extreme
have an have a minor moderate impact on community perception of the impact on community
insignificant impact on community organisation perception of the
Reputation
impact on community perception of the organisation
community perception of the organisation
perception of organisation
the organisation
Environment Near miss Limited spillage/ Chemical, Biological Toxic release (i.e. chemical, Toxic release (i.e.
Broadly defined release of release of or radiological biological, radiological) chemical, biological or
as the Chemical, Chemical, release contained requiring assistance of radiological) with
surroundings in Biological or Biological without external emergency services with no detrimental efect on
which ACT Radiological or Radiological or assistance detrimental afect environment and/or
Health operates, other toxic other toxic agent personnel
including air, agent. contained and
water, land, cleaned up with
natural no evacuation
resources, flora, and no external
fauna, humans assistance
and their required
interrelation.
 DGD12-047
Incident Management Flowchart
1. Identification DOCUMENT Ring Riskman Help Desk
The incident in the
Incident or near miss occurs Clinical Record if
Ph: 6205 4000 if requiring
Notify immediate superior consumer incident assistance or no computer access

Serious incident: consult

Significant Incident SOP

Notify supervisor/manager
Distribute Riskman incident as appropriate DOCUMENT
2. Notification Serious work injury: Notify WorkSafe ACT if a notifiableComplete
incident
Riskman
Consumer harm: Consult
Open Disclosure SOP
report
Serious consumer incident: If after hours notify on-call Executive Director; and
Notify appropriate Clinical Lead

Work injury: consult Safety

Management System

3. Classification DOCUMENT
Staff Accident/Incident
Staff provide an initial outcome rating using the table above. Report if staff incident
Classifiers amend as required.

DOCUMENT
4. Investigation Update Riskman fields
as appropriate

5. Action DOCUMENT
Update Riskman fields
as appropriate

6. Evaluation DOCUMENT
Update Riskman fields
as appropriate
Monitor service provision areas related to the incident for any further incidents
Analyse Riskman data
Update Policies and SOPS
Conduct a Risk/Hazard Assessment if required