High Level Incident Overviews and Strategies

It is an unfortunate reality that no system which delivers complex health care is free from risk or error. It is globally recognised (World Health Organisation, 2017) that errors in healthcare delivery are the cause of unintended harm and at times, associated with poor outcomes for patients.

Ensuring patient safety and the delivery of high quality care at all times is the number one priority for EMHS. To support this, EMHS has a proactive and transparent patient safety culture that uses a non-punitive approach to the reporting of and learning from, clinical incidents or errors.

So that the health service can adequately investigate the causes of clinical incidents, each incident is assigned a rating known as a Severity Assessment Code (SAC) score that guides staff in the type of investigation method to be applied to each event. Clinical incidents that result in serious harm or death (SAC 1) require a very detailed, rigorous investigation facilitated by an expert panel, members of which may at times be completely independent to the health service.

Measuring high level incident overviews and strategies

Clinical incidents can be represented as a rate per 1,000 occupied bed days. This can give an idea of how busy a hospital is at the time that incidents are reported, and can help inform us about how successful the culture of open and transparent reporting is.

When an incident is reported and investigated, one of the things reported is whether a patient is injured and how severe the injury is. We try to learn from every incident, whether or not the incident causes harm, and make changes to systems, processes and procedures to reduce the risk of future incidents happening, and to prevent harm from similar incidents if they do happen. This is the reason that we promote a culture of openness and transparency we prevent future harm If an incident is reported as a near-miss, or causing no harm.

How do we measure up

The graph below shows the combined incident rate for the EMHS hospitals:

  • Armadale Health Service
  • Kalamunda Hospital
  • Bentley Hospital
  • Royal Perth Hospital

Chart: EMHS rate of reporting of clinical incidents per 1,000 occupied bed days: All reported inpatient clinical incidents and inpatient clinical incidents resulting in harm.

Graph: rate of reported clinical incidents/ events resulting in harm per 1,000 OBD

What the figures mean

The graph shows the rate of reported inpatient clinical incidents per 1,000 bed days. The green columns show the rate of all inpatient clinical incidents, and the tan columns show the rate of incidents that resulted in harm of any kind.

The higher total rate of reported incidents and the increasing rate of reporting show that the culture of reporting incidents is healthy and effective. Note that the rate of incidents resulting in harm has remained low – this shows that the health system learns from events and introduces effective programs to prevent and minimise harm resulting from incidents.

Learning from Clinical Incidents

This is an example of learnings from a serious clinical incident.

Situation:

An unwell and malnourished man was admitted to the ICU after being found unresponsive on the floor of his home. During his stay in ICU, the patient was noted to have developed pressure injuries on two parts of his body.

Clinical incident:

The Incident Investigation Panel conducted a thorough assessment of the incident and concluded that the patient’s risk of developing pressure injuries was not identified during screening on admission and subsequent shift changes.

Contributing factors:

The panel determined that the patient should have had preventative measures put in place, such as the use of a special air mattress to minimise the risk of pressure injuries forming while he was receiving care in ICU. The assessment process was not fully adhered to.

Recommendations:

  1. The ICU to align their practice with best practice guidelines for the prevention and management pf pressure injury as published by the Australian Commission on Safety and Quality in Health Care.
  2. Staff education to be provided by the Wound Clinical Nurse Consultant and pressure injury champions.
  3. Pressure injury staging lanyards to be provided to all nursing staff in the ICU to assist in the identification and appropriate staging of pressure injuries.

Lessons learned:

All areas that care for patients, particularly critical care areas, must have ways to ensure that patients are adequately assessed for their risk of developing pressure injuries. Staff training and education is vital to ensuring that patients at high risk are identified and are provided with appropriate means to minimise the risk of these injuries occurring.

Last Updated: 03/09/2019