Clinical incident management guideline
Guideline number: QH-HSDGDL-032-2
Effective date: 1 July 2024
Review date: 1 July 2027
Supersedes: Version 2.0
On this page:
- Purpose
- Scope
- Guideline for clinical incident management
- Supporting and related documents
- Definition of terms
- Approval and implementation
- Version control
1. Purpose
This Guideline provides direction regarding best practice for clinical incident management.
2. Scope
This Guideline applies to Hospital and Health Services (HHSs).
3. Guideline for clinical incident management
Clinical incidents can and do occur in the course of providing healthcare. By consistently managing and effectively responding to clinical incidents, both at the Hospital and Health Service level and at the state-wide level, future clinical incidents and patient harm may be minimised.
Patient Safety Queensland (PSQ), Clinical Excellence Queensland (CEQ), Department of Health, provides resources to help support Iearnings and quality improvement in response to clinical incidents. A range of clinical incident management resources are available on Queensland Health's Best Practice Guide to Clinical Incident Management, factsheets, analysis templates and forms. Clinical incident analysis interactive training modules are available on iLearn and include modules about open disclosure and coronial management.
For all severity assessment code 1 (SAC1) clinical incidents, clinician disclosure should occur within 24 hours of the incident. Open disclosure should be offered to the patient, family or carer with a follow up for those that may initially decline.
All staff have a responsibility when a clinical incident is recognised to report the clinical incident. Most clinical incidents are identifiable at the time of the event. However, clinical incidents can be identified after the event, for example, as a result of a complaint, consumer feedback, audits, meetings (including morbidity and mortality committees, safety and quality committees and team meetings) or following the analysis and/or investigation of a medical device failure or fault.
All SAC1 clinical incident analysis reports completed by HHSs, are submitted to PSQ for recording the date received in the Department’s RiskMan clinical incident reporting information system to meet the 90-day key performance indicator as required by the Patient Safety Health Service Directive.
Clinical incidents reports are reviewed by PSQ and forwarded to relevant quality assurance committees and other relevant committees for the purpose of improving the safety and quality of Queensland’s public and private sector health services. Quality assurance committees assess and evaluate the quality of health services and make recommendations. PSQ reviews clinical incident reports to identify state-wide system issues/trends and emerging risks. The information PSQ acquires and compiles informs statewide patient safety initiatives and is shared more broadly to support learnings and improvements across the public and private (where applicable) health sectors.
3.1 Incident reporting
3.1.1 HHSs should have an established documented local process for identifying, managing, and reporting any clinical incident which has resulted in actual or potential patient harm.
3.1.2 This process should include specific roles and responsibilities for recording all clinical incidents in Queensland Health’s RiskMan clinical incident reporting information system as soon as practicable after the incident has occurred. Severity assessment code 1 (SAC1) clinical incidents should be reported to the Department of Health through RiskMan within one (1) business day of a service becoming aware of the incident.
3.1.3 The local clinical incident processes should also include, or link to, a process for identifying and managing patient safety issues/risks, including issues with medical devices (refer to the: Guideline for Patient Safety Notification System QH-HSDGDL-032-4).
3.1.4 HHSs should have a local process for directly escalating significant clinical incidents to the Director-General, Queensland Health. If there is a question about notifying the Director-General, this can be discussed with the Senior Departmental Liaison Officer by email: SDLO@health.qld.gov.au
3.2 Incident analysis
3.2.1 HHSs should have established documented local process to conduct a preliminary risk assessment within 24 hours for a SAC1 clinical incident as well as other clinical incidents.
3.2.2 HHSs should have an established documented local process for incident analysis and should include the incident/s that will be subject to analysis, the method of analysis (comprehensive or concise) and the roles and responsibilities for those involved with the incident analysis process.
3.2.3 Queensland Health does not mandate or prescribe the type of analysis to be conducted for a SAC1 clinical incident (inclusive of reportable events as defined in the Hospital and Health Boards Regulation 2023).
3.2.4 For a root cause analysis to attract the privileges and protections under the Hospital and Health Boards Act 2011, the SAC1 clinical incident must be a reportable event; noting that a reportable event can be reported under any type of analysis at the discretion of the HHS. Reportable events are those events listed in Section 37 of the Hospital and Health Boards Regulation 2023
3.2.5 The documented local process for incident analysis should include timeframes for the completion of the clinical incident analysis. At a minimum, and as required by the Patient Safety Health Service Directive, SAC1 incidents should undergo incident analysis within 90 calendar days of the clinical incident being reported.
3.2.6 HHSs should have an established documented local process for the inclusion of the patient/family/carer perspective of the incident and should have consumer representation in the clinical incident analysis process including the development of recommendations.
3.2.7 Patient safety issues and/or risks identified during the clinical incident analysis, with the potential for statewide impact, should be reported to PSQ.
3.2.8 The clinical analysis report should be written without using acronyms with the consideration that it can be provided to the patient/family/carer should they wish to access.
3.2.8 A SAC1 clinical incident analysis report should contain:
- a factual description of the event
- the factors identified as having contributed to the event
- recommendations to prevent or reduce the likelihood of a similar event happening again.
3.2.9 HHSs should include a specific role responsibility to submit the SAC1 analysis reports to the PSQ. As required by the Patient Safety Health Service Directive, the SAC1 analysis report should be submitted within 90 calendar days of the incident being reported. Where a SAC1 analysis report cannot be submitted within 90 calendar days of the incident being reported, an email should be sent to PSQ advising of the reason for the delay and the anticipated completion date.
PSQ contact details for SAC1 incident analysis reports:
Phone: 3328 9430
Email: PSQ-SAC1DOCUMENTS@health.qld.gov.au
3.3 Development and implementation of recommendations
3.3.1 HHSs should have an established documented local process for the development of recommendations arising from SAC1 analysis, that should include engaging with relevant stakeholders, (including those responsible for the implementation) and prioritising recommendations based on impact and achievability.
3.3.2 HHSs should have an established documented local process for testing (if necessary) the recommendations before full implementation. The process of developing a recommendation should include identifying a responsible person, identified timelines, progress monitoring, expected outcomes and specific measures to assess the impact and sustainability of the recommendation.
3.3.3 HHSs should have an established documented local process to enable the dissemination of recommendations, key findings and /or learnings with the patient/family/carer and relevant stakeholders. This includes the dissemination of the following information from clinical incident reports including a report resulting from a root cause analysis:
- details of a reportable event (a reportable event is an event listed at s.37 of the Hospital and Health Boards Regulation 2012)
- details of the name and address of the entity responsible for providing the relevant health service
- information contained in the copy of the report including, for example, recommendations about changes or improvements in a policy, procedure or practice relating to the provision of health services, to reduce the likelihood of, or prevent, the same type of event happening again.
3.3.4 HHSs should consider if recommendations may have statewide relevance and submit the findings to PSQ.
3.4 Coronial recommendation management
3.4.1 HHSs should have an established documented local process for recording, considering and actioning each recommendation made by a Coroner to the HHS following a coronial inquest.
3.4.2 The process should consider human rights when deciding if a recommendation is supported, partially supported or not supported, and how recommendations are implemented.
3.4.3 Whilst there is no requirement for a HHS to accept and implement a coronial recommendation, there is a requirement for HHSs to contribute to whole-of-government public reporting about Queensland Health’s response to a coronial recommendation.
3.4.4 HHSs should identify a specific role (person) responsibility for submitting an initial response to a coronial recommendation to PSQ, as required by the Patient Safety Health Service Directive. The response should be submitted by email on the Department’s coronial response template within 90 days of the inquest findings being delivered to psccoronial@health.qld.gov.au. .
3.4.5. HHSs should have a documented plan for implementing and monitoring each recommendation and undertake consultation with PSQ, to ensure implementation adequately addresses the recommendation.
3.4.6 Updates are required to be provided six monthly until the implementation of the recommendation is complete.
3.4.7 Coronial response reporting instructions and templates are available on QHEPS.
PSQ contact details for coronial management:
Phone: 3328 9430
Email: psccoronial@health.qld.gov.au
4. Supporting and related documents
Authorising Health Service Directive
Related guidelines
Legislation
- Hospital and Health Boards Act 2011
- Hospital and Health Boards Regulation 2023
Resources
- Coronial response instructions and template
- Best practice guide to clinical incident management
- Clinical Incident Management Analysis resources
Accreditation references
- National Safety and Quality Health Service. Standards. 2nd ed. 2017 (Updated May 2021)
5.Definition of terms used in this directive
| Term | Definition / explanation / details | Source |
|---|---|---|
Clinical incident | An event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary harm to a patient or consumer; and/or a compliant, loss or damage. | Australian Commission on Safety and Quality in Health Care (ACSQHC) |
Severity assessment code (SAC) 1 | Death or likely permanent harm which is not reasonably expected as an outcome of health care. | Queensland Health Clinical Incident Management Guideline |
6. Approval and implementation
Guideline custodian
Executive Director, PSQ, Clinical Excellence Queensland
Approving officer
Deputy Director General, Clinical Excellence Queensland, Department of Health
Approval date: 2/05/2024
Effective from: 1/07/2027
7. Version control
| Version | Date | Prepared by | Comments |
|---|---|---|---|
| 1.0 | 01/08/2013 | HSCI | New Guideline |
| 2.0 | 31/01/2021 | PSQIS | Updated email addresses, phone numbers and the name Patient Safety Unit, to Patient Safety and Quality Improvement Service. Minor clerical amendments in line with the Queensland Health Editorial style guide 2019. Modified requirement of coronial reporting from quarterly to six monthly. Added PSQIS role in provision of resources and on-line education. |
| 3.0 | 02/05/2024 | PSQ | Updated to new Branch title – Patient Safety and Quality (PSQ) Minor clerical edits throughout document in line with the Queensland Health Editorial style guide 2019. Update to links Section 2 – review of the scope Section 3 – Additional information on available resources and responsibilities of HHS and PSQ 3.1.3 Additional reference to medical devices 3.2.1 New section – inclusion of preliminary risk assessment within 24 hours 3.2.2 New section - no mandate to type of analysis 3.2.3 New section – No mandate on type of analysis 3.2.4 New section – RCA and Reportable Events 3.2.6 New section – inclusion of patient/family/carer perspective and consumer representation in the analysis process 3.2.7 New section – Issue/risks with potential for statewide impact 3.2.8 New section – Reports written with consideration to be provided to patient/family/carer 3.3.1 Additional information 3.3.2 Amendment with new information relating to recommendation implementation requirements 3.3.3 New section – sharing of key findings, recommendations, and learnings as per HOLAB Act 3.3.4 New section – statewide recommendation. 3.4.2 Review of the Coronial recommendation section including a new reference to the inclusion of consideration of human rights in decision making 3.4.5 Amendment to previous 3.4.3 to consult with PSQ on updates to recommendations Update to definitions of Clinical incident. |