Patient Incident Management in Safety Learning System

Effective from 1 July 22, the Safety Assessment Code (SAC) rating system for patient incidents is replaced by the Incident Severity Rating (ISR).


Some tools and SLS topic guides remain under review.


If you read a document that refers to the SAC, or where the SAC is mentioned, you should interpret that as the ISR until all resources are updated.

 

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 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.

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.

After an incident occurs, there are five main actions that together, will improve the safety and quality of care:

  • Immediate care and treatment are provided.
  • The incident is then recorded into Safety Learning System (SLS) by the notifier.
  • The incident is openly disclosed to the consumer.
  • The manager reviews this report, investigates the incident and documents action(s).
  • The manager and/or relevant committee(s) review data relating to types of incidents, or locations where incidents occur. The data arising from incidents is used to plan improvements to the quality of patient care.

SLS Patient Incident Management Toolkit

The Patient Incident Management and Open Disclosure Policy Directive (PDF 1.9MB) describes a standardised system for managing patient incidents and open disclosure.

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.

Tool 1 – How to report a patient incident

SLS (Safety Learning System) guide – How to report a patient incident (PDF 648KB) is one of series of guides for new users of Safety Learning System (SLS). It describes and illustrates the steps to report and classify a patient incident online into SLS. Key features of SLS are explained.

Tool 2 – Incident Severity Rating

The Incident Severity Rating (PDF 158KB) assists readers to assign an ISR to a patient incident, based on the patient outcome and treatment required. 

Tool 3 — How to manage a patient incident

The SLS (Safety Learning System) guide – How to manage a patient incident (PDF 1.1MB) is one of series of guides for managers about Safety Learning System (SLS). It describes and illustrates the steps to classify and manage (review, investigate and analyse) a patient incident in SLS. Key features of SLS, ISR and legal considerations are explained.

Tool 4 – Reporting and management requirements for Safety Assessment Code (SAC) 1 and SAC 2 patient incidents flowchart

The Reporting and management requirements for Safety Assessment Code (SAC) 1 and SAC 2 patient incidents flowchart (PDF 116KB) illustrates the steps in the reporting and management of SAC 1 and 2 rated patient incidents. These harmful incidents have additional requirements for notification to senior managers, and may require additional investigation.

Tool 5 - Diagram of incident management and open disclosure

This Diagram of incident management and open disclosure (PDF 198KB) illustrates all steps and components of patient incident management, encircling the principles for open disclosure with patients and carers.

Using Safety Learning System (SLS) for patient incident management

The Safety Learning System is the system SA Health uses for reporting Patient incidents and near misses, and for recording and managing the investigation of incidents.

It is an interactive system that has functions and capability that can:

  • assist notifiers to provide accurate information
  • assist Patient Incident Managers in their role, and monitor progress with incident management
  • safely store and record the information
  • allow information to be shared between staff directly involved with the incident
  • provide governance committees and senior managers with tailored reports summarising groups of incidents and data for use in monitoring and planning quality improvement.

Reporting incidents into SLS

All staff must report a patient incident into SLS. Assistance to get started is available on the Safety Learning System page. Staff have a responsibility to report incidents accurately.

SLS resources provide information for staff on using the SLS to report an incident or near miss. They describe the features and functions of the SLS.

Classifying Patient incidents

There are 3 levels of classification of the type of incident. Tool 1 – SLS (Safety Learning System) guide — How to report a patient incident (PDF 648KB) provides further information.

NDIS serious reportable incidents

NDIS Reportable Incidents are specific types of serious incidents that have, or are alleged to have occurred in connection with the provision of supports and services by registered NDIS providers (National Disability Insurance Scheme (Incident management and Reportable Incidents) Rules 2018; Part 3.)

The NDIS Serious Reportable Incident Policy (PDF 490KB) and Mandatory Instruction describes the process of identifying incidents which have occurred inside and outside of a SA Health service and the required report(s). Use the NDIS Serious Reportable Incident Template (DOCX 139KB) as a guide to reporting and notifications.

SA Health requires any serious incidents identified in NDIS care provision to be notified according to Appendix 1 Mandatory Instructions regardless of who the NDIS provider is.

Serious incidents involving a NDIS participant are required to be notified to:

Patient Incident Managers — Information

Patient Incident Managers have responsibility for the review, investigation, analysis and taking action to prevent recurrence. In some cases Patient incident managers will also need to produce reports of incident data. The roles and responsibilities of Patient Incident Managers are described in the Policy Directive (PDF 1.9MB).

Tool 3 – SLS (Safety Learning System) guide – How to manage a patient incident (PDF 1.1MB) describes the steps to classify and manage (review, investigate and analyse) a patient incident. This guide illustrates the key features and functions of SLS to assist managers. ISR scoring and legal considerations are also explained.

Some SLS topic guides provide additional information for managers about specific types of incidents. These include:

Patient Incident Managers — Login access

In order to be able to perform these roles, managers will need to apply for 'manager access' to SLS incidents relevant to your work and area of responsibility. Complete the SLS User Access Request form (DOCX 57KB) and forward to your local SLS Site Administrator.

A list of Patient SLS administrators is available through the link at the top of the front page in the Safety Learning System.

Patient Incident Managers — Incident Escalation Pathway

Clinical Incident Brief

Harmful incidents (generally ISR 1 and ISR 2) have additional requirements for notification to senior managers, and may require additional investigation.

The use of a template to brief the Chief Executive (DOCX 63KB) in the Department for Health and Wellbeing (DHW) is required to  provide the Chief Executive  with consistent high quality information, in a timely fashion. This template is for LHNs and state-wide services to use for these communications.

There is a Guide for completing a Clinical Incident Brief (PDF 123KB) (CIB). The purpose of this guide is to assist staff to use the template to complete the Clinical Incident Brief (CIB).

Tool 4 – Reporting and management requirements for Safety Assessment Code (SAC) 1 and SAC 2 patient incidents flowchart (PDF 116KB) illustrates the steps in the reporting and management of SAC 1 and 2 rated patient incidents.

Legal protection of information in SLS

Information recorded in SLS that is related to a patient incident should be considered in the same way that information in a patient medical record (health record) is. That is information should be accurate, succinct, factual and objective.

Information arising from a Part 7 review or an RCA conducted under the protection of Part 8 of the Health Care Act 2008 cannot be released other than in a de-identified format. Please contact Safety and Quality Managers prior to release of any information about incident.

Committees that have been designated as Part 7 protected committees for Safety and Quality assessments are authorised to undertake investigation of serious incidents.

In certain circumstances a Root Cause analysis (RCA) may be conducted under the protection of the Health Care Act 2008, Part 8.

Cluster incidents are system issues affecting more than five patients. The type of review required is a Lookback review

See the following for more information regarding serious incidents:

Removal of Part 7 protection of Safety Learning System

On 15 September 2016 the protection of SLS under Part 7 of the Health Care Act 2008 was removed. The Frequently Asked Questions (PDF 320KB) information sheet outlines the effect of this change.

Education and training

It is expected that all staff will complete the online eLearning course on Patient Incident Management and open disclosure. Access is via the DHW Safety and Quality intranet page.

Health services should use the resources in the SLS Patient Incident Management toolkit to guide incident management and quality improvement.

SLS topic guides

Frequently asked questions

Fact sheets

Relevant tools

Further information available

Updates

The SLS Program Team is continuously working to enhance and improve the SLS application.

All change requests provided by local SLS site administrators are reviewed by the Technical Advisory Groups and when required the SLS Governance Board for approval.

SLS Notices are provided to update users on changes to the system. SLS Notices can be found on the top banner on the front page of SLS.

Contact

All queries regarding patient incidents can be directed to your local SLS site administrator. 

A list of Patient SLS administrators is available through the link on the top banner on the front page in the Safety Learning System.

SLS Program Team

Email: safetylearningsystem@sa.gov.au