Clinical incident management and open disclosure

Incidents can occur while receiving health care and appropriate clinical incident management will improve safety and care for patients, as well as assist the workforce to identify, report, manage and learn from incidents.

SA Health promotes an accountable and proactive approach to incident management in line with the Australian Commission on Safety and Quality in Health Care Incident Management Guide and the Australian Open Disclosure Framework.

Clinical incident management

A clinical incident is an event or circumstance that occurs during health care that could have, or did, result in harm to a patient, client or consumer.

Clinical incident management includes reporting of incidents, open disclosure with the person affected and their family and carers, review of the incident, and actions to prevent or reduce the impact of the incident happening again.

After a clinical incident, both the person affected, their family and carers, and staff are involved in incident review.

The person affected and their family and carers are informed when an incident takes place and can contribute to the incident review.

Staff learn from the review of incidents and share learnings with other clinicians and consumers.

Open disclosure

Open disclosure is an apology or expression regret, a factual explanation of what happened, an opportunity for the person affected to relate their experience, and an explanation of the steps being taken to manage the event and prevent recurrence.

Open disclosure is an important part of the incident management process and allows the person affected to share their experience of the incident and ideas for improvement.

The open disclosure process may take place over several meetings or conversations and involves:

  • an apology for what went wrong
  • an explanation to help the person affected to understand what happened and how the incident may affect their care
  • an opportunity to listen to the person’s experience
  • an explanation of the steps the health service will be taking to prevent the incident happening again.

Sometimes open disclosure happens at the time of the incident, such as a wrong medication being given. At other times, incidents can be realised after the incident has occurred, such as a referral being missed.

For more information about your healthcare rights and how open disclosure is conducted, read the Open Disclosure – what to expect if you experience harm during healthcare? (PDF 217KB)

Root Cause Analysis

For some serious incidents, health services will perform a Root Cause Analysis (RCA), which uses a defined process to find out:

  • what happened during care to cause harm
  • why it happened
  • how it can be prevented from happening again.

The RCA helps the health system learn from an incident and identify areas of improvement to ensure safe and quality patient care.

For more information, read the Root Cause Analysis fact sheet for patients (PDF 154KB).

Accreditation, education and reporting

All SA Health services are required to be accredited against the National Safety and Quality Health Service (NSQHS) Standards every three years to ensure relevant systems are in place and are working effectively to provide the expected standard of patient care.

Staff receive education and training in relation to their responsibilities for incident management and open disclosure.

SA Health uses the Safety Learning System (SLS) platform to report and document clinical incident management.

Policy and guidelines

The SA Health Clinical Incident Management Policy (PDF 789KB) outlines the systems and processes for managing clinical incidents and open disclosure. The policy is supported by four ‘how to’ guidelines.


How to conduct a:


If you have concerns about your or someone else's experiences, speak with your care team who will be able to direct you to a relevant staff member.

If you need additional assistance, contact the Department for Health and Wellbeing Patient Safety Team at