❓ WA Parliamentary Question on Notice regarding the monitoring and reporting of clinical incidents within the WA Public Health System between March 2012 and March 2013. The response details the monitoring processes, incident numbers, severity levels, and contributing factors.
AnsweredQoN 451Legislative Assembly
QuestionView source ↗
I refer to the occurrence of ‘clinical incidents’ in the Western Australian Public Health System and ask: (a) how does the Government monitor ‘clinical incidents’ in the Western Australian Public Health System; (b) what is the total number of ‘clinical incidents’ that occurred in the Western Australian Public Health System from March 2012 to March 2013; and (c) of the incidents above: (i) how many were categorised as Severity Assessment Code 1, 2 and 3, respectively; (ii) at which hospitals did they occur; (iii) in which areas of each hospital did they occur; (iv) what were the adverse events that resulted in a ‘clinical incident’ occurring; and (v) for how many ‘clinical incidents’ was ‘no available beds’ a contributing factor?
AnswerView source ↗
Answered
1 August 2013
Responded by
Minister for Health
Response time
51 days
(a) Clinical incident reporting and monitoring is a component of patient safety management programs. It has the function of raising awareness and generating an environment that promotes safety. A high reporting rate usually demonstrates a strong patient safety culture. A key component of incident reporting and management is the health service clinical investigation and response to the incident. Lessons are learned to prevent future similar occurrences.
The Western Australian Department of Health (DOH) monitors clinical incidents via the state-wide Clinical Incident Management (CIM) Program*. The CIM program involves:
- All Health Services (HS) notifying clinical incidents into a state-wide Clinical Incident Management System (AIMS) database and then investigating clinical incidents at a local level.
- Notifying hospitals /organisations must forward an investigation report on the clinical incident to the WA DOH.
- HS have 12 months to implement the clinical incident investigation recommendations and evaluate their effectiveness. The WA DOH monitors whether recommendations have been implemented and/or completed.
- All hospital sites are able to access the clinical incident database to analyse clinical incident trends. Each HS also monitors clinical incident trends at a HS level, and the DOH analyses clinical incident trends at a State level.
- An annual report of clinical incidents occurring in WA is published by the WA DOH.
* Department of Health, Western Australia. Clinical Incident Management Policy. (2012). Perth: Patient Safety Surveillance Unit (PSSU), Performance Activity and Quality Division (
http://www.safetyandquality.health.wa.gov.au/docs/aims/CIMS_Policy_2012.pdf
)
(b) The total number of notified clinical incidents from the WA Public Health System was 21,315 (1 March 2012 to 1 March 2013).
(c)(i) Clinical incidents categorised as Severity Assessment Code 1, 2 and 3:
Severity Assessment Code
Level
Number of incidents
%
SAC 1 - clinical incidents
causing actual (or the potential
for) serious harm or death
209
0.98
SAC 2 - clinical incidents
causing moderate harm
2,971
13.93
SAC 3 - clinical incidents
causing minor or no harm
18,135
85.08
Total
21,315
100.0
(ii) 91 public hospitals and health service regions notified clinical incidents during the period 1 March 2012 to 1 March 2013 ([see tabled paper no] for specific hospital reporting).
(iii) This data is not collected as a mandatory field.
(iv) An adverse event is the same as a clinical incident.
"An adverse event is a clinical incident where an injury/harm is caused by medical management or complication thereof, instead of the underlying disease. It results in an increase in the level of care and/or prolonged hospitalisation and/or disability at the time of discharge."
* Medical management refers to management under health care services.
* Department of Health, Western Australia. Clinical Incident Management Policy. (2012). Perth: Patient Safety Surveillance Unit (PSSU), Performance Activity and Quality Division (
http://www.safetyandquality.health.wa.gov.au/docs/aims/CIMS_Policy_2012.pdf
)
Please Note that comprehensive annual reports are available from the following website:
http://www.safetyandquality.health.wa.gov.au/clinical_incid_man/sentinel_events_annreports.cfm
(v) 89 or 0.4% of clinical incidents identified "unavailability of a bed" as one possible contributing factor to the clinical incident occurring.
The Western Australian Department of Health (DOH) monitors clinical incidents via the state-wide Clinical Incident Management (CIM) Program*. The CIM program involves:
- All Health Services (HS) notifying clinical incidents into a state-wide Clinical Incident Management System (AIMS) database and then investigating clinical incidents at a local level.
- Notifying hospitals /organisations must forward an investigation report on the clinical incident to the WA DOH.
- HS have 12 months to implement the clinical incident investigation recommendations and evaluate their effectiveness. The WA DOH monitors whether recommendations have been implemented and/or completed.
- All hospital sites are able to access the clinical incident database to analyse clinical incident trends. Each HS also monitors clinical incident trends at a HS level, and the DOH analyses clinical incident trends at a State level.
- An annual report of clinical incidents occurring in WA is published by the WA DOH.
* Department of Health, Western Australia. Clinical Incident Management Policy. (2012). Perth: Patient Safety Surveillance Unit (PSSU), Performance Activity and Quality Division (
http://www.safetyandquality.health.wa.gov.au/docs/aims/CIMS_Policy_2012.pdf
)
(b) The total number of notified clinical incidents from the WA Public Health System was 21,315 (1 March 2012 to 1 March 2013).
(c)(i) Clinical incidents categorised as Severity Assessment Code 1, 2 and 3:
Severity Assessment Code
Level
Number of incidents
%
SAC 1 - clinical incidents
causing actual (or the potential
for) serious harm or death
209
0.98
SAC 2 - clinical incidents
causing moderate harm
2,971
13.93
SAC 3 - clinical incidents
causing minor or no harm
18,135
85.08
Total
21,315
100.0
(ii) 91 public hospitals and health service regions notified clinical incidents during the period 1 March 2012 to 1 March 2013 ([see tabled paper no] for specific hospital reporting).
(iii) This data is not collected as a mandatory field.
(iv) An adverse event is the same as a clinical incident.
"An adverse event is a clinical incident where an injury/harm is caused by medical management or complication thereof, instead of the underlying disease. It results in an increase in the level of care and/or prolonged hospitalisation and/or disability at the time of discharge."
* Medical management refers to management under health care services.
* Department of Health, Western Australia. Clinical Incident Management Policy. (2012). Perth: Patient Safety Surveillance Unit (PSSU), Performance Activity and Quality Division (
http://www.safetyandquality.health.wa.gov.au/docs/aims/CIMS_Policy_2012.pdf
)
Please Note that comprehensive annual reports are available from the following website:
http://www.safetyandquality.health.wa.gov.au/clinical_incid_man/sentinel_events_annreports.cfm
(v) 89 or 0.4% of clinical incidents identified "unavailability of a bed" as one possible contributing factor to the clinical incident occurring.
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