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Patient Incident Management and Open Disclosure Policy Directive
SA Health recognises that incidents can occur while providing health care, some of which may have serious consequences for consumers.
Effective incident management and open disclosure processes are attributes of high-quality health service organisations, and important elements of quality improvement and a consumer or patient-centred approach to healthcare.
The Patient Incident Management and Open Disclosure diagram shows that after a patient incident, there are two separate but linked and related processes to ensure that:
In line with Good medical practice: a code of conduct for doctors in Australia, 2014 and other professional codes, SA Health promotes open disclosure with consumers; a quality improvement and non-punitive approach to incident management; and participation by all staff in reporting and learning from incidents.
After an incident occurs, there are five main actions that together, will improve the safety and quality of care:
The Patient Incident Management and Open Disclosure Policy Directive (PDF 1.9MB) describes a standardised system for managing patient incidents and open disclosure.
The map of documents and tools for patient Incident Management and Open Disclosure (PDF 61KB) provides a one page list of the current documents and tools.
The guide to using the Patient Incident Management and Open Disclosure toolkits (PDF 108KB) provides a summary of each document and resources that accompany the Policy Directive.
Safety Learning System Patient Incident Module Protection and disclosure
SA Health takes the protection of individuals’ personal information very seriously, and has systems in place to make sure that information is only released once safeguards have been met and in response to authorised requests.
National Safety and Quality Service Standard 1: Clinical Governance
The NSQHS Standard 1: Clinical Governance describes actions that need to be met for accreditation:
1.11 The health service organisation has organisation-wide incident management and investigation systems, and:
1.12 The health service organisation:
See also the ACSQHC resource Australian Open Disclosure Framework
The term incident management includes all the activities involved in the reporting, notification or documentation of an incident or near miss; and the review, investigation and analysis of the individual incident or groups of incidents, for the purpose of improving the safety and quality of the health service and the care provided. See Patient incident management for more information.
A patient incident is any event or circumstance which could have (near miss) or did lead to unintended and/or unnecessary psychological or physical harm to a patient, that occurs during an episode of health care.
SA Health promotes an open and positive approach to incident management, and recognises that most incidents occur because of problems with systems, rather than with individuals.
The Patient Incident Management toolkit includes resources that have been developed for staff to report, investigate, analyse and take action to prevent recurrence of an incident.
Incidents that have serious adverse outcomes for consumers may require:
The open disclosure of incidents is an important part of the incident management process and is essential to a consumer-or patient-centred approach to care.
Open disclosure is the process of providing an open, consistent approach to communicating with patients/consumers, their family, carer and/or support person following a patient incident. This process includes expressing regret or saying sorry.
The Open disclosure toolkit includes resources have been developed for staff to manage the open disclosure process for level 1 (SAC 1 and 2) and level 2 (SAC 3 and 4) incidents.
Consumer information and resources are available on the Open disclosure for consumers page.
It is expected that all staff will complete the online eLearning course on Patient Incident Management and open disclosure. Access is available via the DHA Safety and Quality intranet page.
Health services should use the resources in the
See the Patient incident management in Safety Learning System page to learn about using SLS.
Further information about using SLS for reporting and managing patient incidents, and recording open disclosure is available on the Patient incident management in Safety Learning System page.
Additional information is available on the Safety Learning System page.
Each health service has staff with expertise in incident management and open disclosure. They have roles in Safety and Quality, Clinical Governance and/or Risk Management. Queries should be addressed to these staff in the first instance.
Clinical Governance Unit