Patient Safety Net

Guideline number: QH-GDL-985

Effective date:   10 January 2025

Review date: 10 January 2028

Supersedes: New document

On this page:

1. Statement
2. Purpose
3. Scope
4. Principles
5. Requirements
6. Aboriginal and Torres Strait Islander considerations
7. Human Rights
8. Legislation
9. Supporting documents
10. Definitions
11. Approval and implementation
12. Version Control

1. Statement

This guideline outlines the responsibilities of Hospital and Health Services (HHSs), the Department of Health and the Queensland Ambulance Service (QAS) to deliver the Patient Safety Net program.

2. Purpose

The Patient Safety Net program has been developed to provide staff with a confidential, supportive, and transparent process for raising a patient safety concern they feel has not been addressed through the standard reporting processes in a timely, or sufficient way.

3. Scope

This guideline applies to Queensland Health employees, agents, volunteers, students, contractors, consultants, and managed service providers working for the Divisions within the Department of Health, and for the Hospital and Health Services and the Queensland Ambulance Service.

This guideline applies to any Queensland Health entity undertaking the Patient Safety Net program.

Patient Safety Net complements existing patient safety systems. It is not intended:

• to replace, nor negate existing clinical incident management processes
• for urgent patient safety concerns, or clinical deterioration
• for concerns raised specifically about staff safety without a patient safety consideration
• to replace human resources processes.

4. Principles

The following principles underpin the successful implementation of the Patient Safety Net program:

• Enhancing clinical governance systems

  Patient Safety Net provides an opportunity to strengthen clinical governance systems in HHSs and the QAS by providing a complementary pathway for escalation of patient safety concerns and their management.

• Promoting psychological safety
  

  Patient Safety Net is designed to support the psychological safety of staff reporting a patient safety concern to an independent and trained Patient Safety Steward without fear of reprisal. Contemporary evidence suggests psychological safety in the workplace can contribute to improved reporting and, ultimately, better patient outcomes.

• Protecting privacy and confidentiality

  Protect the privacy and confidentiality of staff and patients involved in reporting a concern in accordance with Australian Privacy Principles, the Information Privacy Act 2009, the Hospital and Health Boards Act 2011 and the Workplace Health and Safety Act 2011

• Communicating outcomes

  Keep the Patient Safety Net reporter informed throughout the concern review process and of the outcomes to foster trust with the reporter and reduce the burden of staff reporting the same concern through multiple avenues. Privacy and confidentiality requirements may limit the amount of information shared with the reporter, for example, where performance and disciplinary measures involving staff are concerned.

5. Requirements

A patient safety concern could involve potential or actual patient harm which could be physical and/or psychological. The program complements existing patient safety and quality mechanisms that are operationalised throughout all HHSs and the QAS.

This guideline specifies minimum actions required to operationalise Patient Safety Net.

5.1. Governance

5.1.1. Hospital and Health Services and Queensland Ambulance Service Patient Safety Net oversight committee

Each HHS and the QAS will convene a Patient Safety Net oversight committee or utilise an existing committee to act as the oversight committee to:

• oversee the management of patient safety concerns reported to the HHS/QAS Patient Safety Steward, including promoting accountability of key stakeholders involved in the patient safety review
• monitor the implementation of recommendations
• manage conflicts of interest
• direct the promotion of the Patient Safety Net program within their organisation.

Minimum requirements

Minimum requirements of the oversight committee are that it will:

• be multidisciplinary
• have a minimum of three members and include the HHS Patient Safety Steward(s)
• include at least one member of the HHS/QAS Executive Leadership Team
• align with local governance arrangements to enable escalation to the Health Service Chief Executive as needed
• ultimately report to their HHS Board safety and quality committee
• maintain appropriate confidentiality of Patient Safety Net Reports, including how information is reported between governance committees.

Information shared with oversight committee

Maintaining reporter confidentiality is a core principle of the Patient Safety Net program.

A recommended approach is to:

• remove details that make the reporter identifiable and do not share unnecessary details of a concern
• use discretion sharing details that identify other people within the details of the concerns and naming specific units/wards, where the information will easily identify the reporter
• consider any conflicts of interest that committee members may encounter and seek to address the conflict of interest before sharing details of the concern.

In every instance, maintaining confidentiality of the reporter needs to be balanced with the required information disclosure to appropriately respond to the concern. While the HHS/QAS Patient Safety Steward has the discretion to withhold the identity of a reporter, the oversight committee has the authority to overrule this decision if they believe withholding the identity places a patient or another person at significant risk of harm, or there is another legislated requirement to reveal this information. When this occurs formal documentation is required.

5.2. Hospital and Health Service and Queensland Ambulance Service responsibilities

5.2.1. Hospital and Health Services and Queensland Ambulance Service executive sponsor and executive leadership

Each HHS and QAS will have an executive sponsor responsible for:

• championing the Patient Safety Net program within the organisation
• establishing a Patient Safety Net Oversight Committee
• escalating concerns as required, raised by the oversight committee.

More broadly, the Executive Leadership Team will be responsible for promoting appropriate use of Patient Safety Net reporting, protecting the psychological safety of staff accessing the program and timely review of patient safety concerns escalated to the Executive Leadership Team.

5.2.2. Appointment of Hospital and Health Services and Queensland Ambulance Service Patient Safety Steward(s)

Each HHS and QAS will:

• appoint at least one HHS/QAS Patient Safety Steward at a suitable level of experience and seniority (refer to Role Description)
• provide appropriate line management for the Patient Safety Steward and ensure succession planning for business continuity (for example, leave coverage)
• support the appointed steward(s) to participate in the minimum recommended training and orientation
• recognise the independence of the HHS/QAS Steward and their authority to act, as well as recognising the HHS/QAS Steward as a Proper Authority for Public Interest Disclosure
• Provide psychosocial supports for the HHS/QAS Patient Safety Steward. This should include access to supervision/mentoring should the steward require it
• provide a direct line of communication for the Patient Safety Steward to escalate concerns to the Chief Executive when appropriate
• ensure that HHS/QAS Patient Safety Steward has access to a range of health service facility metrics to review concerns (for example, patient complaints, clinical incident data).

5.2.3. Hospital and Health Services and Queensland Ambulance Service Patient Safety Steward Responsibilities

The HHS/QAS Patient Safety Stewards are responsible for:

• receiving and actioning patient safety concerns, in relation to actual or potential physical and/or psychological patient harm raised by HHS and QAS staff
• working collaboratively with relevant internal stakeholders (for example, executives, Clinical Governance/Patient Safety Units, senior managers, clinical and non-clinical staff, and consumers) to facilitate review of concerns and ensuring corrective action is taken
• participating in training and Patient Safety Steward network meetings
• providing feedback to all known reporters with the outcome of the review
• reporting and documenting patient safety concerns within the RiskMan steward module to maintain data security, confidential management of information and for reporting purposes.

5.2.4. Patient Safety Net Champions

Hospital and Health Services and the Queensland Ambulance Service will:

• identify Patient Safety Net Champions to support the program by providing advice and information to staff about the purpose of Patient Safety Net and the role of the Patient Safety Steward
• support Patient Safety Net Champions to participate in training, skills development, and networking specific to their role.

5.2.5. Communicating for safety training

It is strongly recommended that HHSs and QAS implement a communicating for safety training program, which equips staff with skills and a framework to raise patient safety concerns and supports leaders to respond effectively.

5.3. Department of Health responsibilities

The department will:

• appoint a Department of Health Patient Safety Steward, with appropriate line management and succession planning
• provide minimum recommended training, orientation, and ongoing support for Department of Health and HHS/QAS Patient Safety Stewards
• manage the governance of the Patient Safety Net program, including reporting to the Clinical Excellence Queensland System Quality and Safety Review Committee on Systemic issues identified through reports made to the Department of Health Patient Safety Steward and program performance monitoring
• organise statewide strategic communications to raise awareness of the Patient Safety Net program
• provide Patient Safety Net education and training for HHS/QAS Safety Stewards
• support HHS/QAS Safety Stewards to develop and maintain local training materials for staff (clinical and non-clinical), champions, managers, directors, executive and Boards
• maintain and update the RiskMan Steward module.

5.3.1. Department of Health Patient Safety Steward responsibilities

The Department of Health Patient Safety Steward is responsible for:

• governance and management of the Patient Safety Net program
• developing and maintaining a Patient Safety Steward support network
• providing support and advice to HHS/QAS Patient Safety Stewards in responding to patient safety concerns
• coordinating a response to complex, systemic, or significant patient safety concerns and those involving multiple HHSs/QAS on the request of those HHSs/QAS
• escalating systemic or significant concerns where required to the Executive Director, Patient Safety and Quality, Clinical Excellence Queensland (CEQ) and if deemed necessary, the Deputy Director General, CEQ
• reporting on overall Patient Safety Net program performance
• co-ordinate a Patient Safety Net Community of Practice for Patient Safety Net Champions.

5.4. Management of patient safety concerns

Management of patient safety concerns is detailed in the Patient Safety Steward Handbook. However, minimum requirements and key considerations are addressed below:

• Only concerns involving a risk that relates to patient safety can be managed through thePatient Safety Net program.
• Patient Safety Concerns will be recorded and managed in the Riskman steward module. Where staff do not wish to be identified, the report can be made anonymously by the staff member (anonymous report) or confidentially - if a Patient Safety Steward knows their details (confidential report).
• Straightforward, easily resolved concerns should be recorded in the module, as well as those reported through the program that are ultimately deemed out of scope. This is for data management and quality improvement purposes. All patient safety concerns that a steward is made aware of should be entered into the module.
• Patient Safety Stewards have a duty of care to address all patient safety concerns they are made aware of where there is a likelihood of harm occurring to a patient or another person. If Stewards are required to escalate a concern, they will inform the reporter of how this will be managed to mitigate any potential retaliatory behaviour. See Privacy and Confidentiality (below) for further details.
• Following a review of the concern, the Patient Safety Stewards (HHS/QAS/Department of Health) will work with key stakeholders to develop recommendations and corrective actions as needed.
• Monitoring of progress, including monitoring implementation of recommendations will be the responsibility of the relevant Patient Safety Steward and the oversight committee at each HHS/QAS.
• Regular and planned communication with reporters including the outcome (where appropriate to do so), is a core principle of an effective Patient Safety Net response.

5.5. Data management and program reporting

Use of the Riskman steward module is described in detail in the RiskMan Steward module: Quick guide for Patient Safety Stewards.

Data management and program reporting will occur at both the department and HHSs/QAS levels. Requirements are set out below:

• All Patient Safety Stewards will collect a minimum data set to enable monitoring, improvement, and reporting activities. The minimum data set is determined by mandatory fields in Riskman and includes:
  • location details
  • dates
  • reporter details (including anonymous reporting selections)
  • concern source
  • if a concern is in scope or out of scope
  • concern closure details
• Other information collected includes:
• type/nature of concern
• timeframes from initial report to provision of feedback and/or resolution/closure
• referral to or notification of external bodies
• risk management and corrective action fields
• Department of Health are the data custodians of Patient Safety Net data within the Patient Safety Net Riskman module. This includes maintaining data quality, system maintenance and modifications.
• Department of Health will undertake quarterly reporting of program activity to the Clinical Excellence Queensland System Quality and Safety Review Committee.
• As system custodians, the Department of Health will create and maintain Riskman steward module reporting templates for both department and HHS/QAS reporting purposes.
• Department of Health will conduct quarterly audits (including monitoring current user access) for quality improvement purposes and provide feedback to HHSs/QAS.

5.6. Privacy and confidentiality

The Patient Safety Net program is designed for reporters to share their identify to the degree that they feel comfortable to do so. While staff are encouraged to disclose their identity when reporting a concern (so additional details can be sought during review of the concern and outcomes can be communicated), they have the option of reporting their concern anonymously.

Confidentiality of patient safety concerns must be maintained where cross-reporting occurs between a HHS/QAS oversight committee and other governance committees.

5.6.1. Limitations to maintaining confidentiality

Where a reporter does disclose their identity to a Patient Safety Steward and there is actual or potential harm to a patient, the steward may have a legal obligation to report the concern. This may necessitate revealing identifiable information, both about the reporter and anyone who is implicated in the patient safety concern. This will be dealt with as sensitively as possible, limiting the information strictly to those responsible for its resolution and concerns about retaliatory behaviour will be actively addressed.

If the matter is identified as a Public Interest Disclosure (PID), there are specific confidentiality provisions, including protections for reporters, that must be adhered to pursuant to Section 65 of the Public Interest Disclosure Act 2010. Suspected Public Interest Disclosures will be referred to a proper authority for assessment in accordance with the Public Interest Disclosure policy. However, the Patient Safety Steward will continue to play a role in communicating with the reporter throughout the resolution process.

Certain external investigatory processes, such as requests from the coroner or subpoenas, may also require release of identifiable information related to patient safety concerns recorded for the purposes of the Patient Safety Net program.

5.7. Conflicts of interest

If a Patient Safety Steward (or any other staff member involved in reviewing a concern) identifies an actual, perceived, or potential conflict of interest they must declare it and manage it in accordance with local conflict of interest policies and procedures, raise it with their line manager, and notify the Department of Health Patient Safety Steward.

6. Aboriginal and Torres Strait Islander considerations

Achieving health equity and improving Aboriginal and Torres Strait Islander health outcomes is a Queensland Health priority. Ensuring culturally appropriate responses for both patients and staff as part of resolving a patient safety concern involving First Nations consumers and/or staff members is essential. HHSs, the QAS and the Department of Health should utilise the expertise of internal Aboriginal and Torres Strait liaison services and/or the First Nations Health Division, to ensure a culturally appropriate response when concerns with a cultural consideration are received.

Consideration of formal governance and operational arrangements to ensure a structured response to patient safety concerns involving either First Nations consumers or staff should be considered by each participating organisation, aligned to their Health Equity Strategy, and tailored to individual context.

7. Human rights

Certain actions or decisions taken, when reviewing a patient safety concern under the Patient Safety Net program, may engage some human rights, in particular Section 25 Right to privacy and reputation, which provides that: A person has the right – (a) not to have the person’s privacy, family, home, or correspondence unlawfully or arbitrarily interfered with; and (b) not to have the person’s reputation unlawfully attacked.

8. Legislation

• Health Ombudsman Act 2013
• Hospital and Health Boards Act 2011
• Public Interest Disclosure Act 2010
• Public Sector Act 2022
• Information Privacy Act 2009
• Industrial Relations Act 2026
• Human Rights Act 2019
• Coroners Act 2003
• Managing the risk of psychosocial hazards at work Code of Practice 2022
• Work Health and Safety Act 2011

9. Supporting documents

• Best practice guide to clinical incident management (Second edition, January 2023)
• Public Interest Disclosure (QH-POL-202: 2019)
• Code of Conduct for the Queensland Public Service
• Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. 2nd ed.
• Making Tracks Together - Queensland's Aboriginal and Torres Strait Islander Health Equity Framework.

10. Definitions

11. Approval and implementation

Version Control