DGD12-047
Standard Operating Procedure
Incident Management
Purpose
The incident management system provides a step by step process for staff to follow when an
incident occurs. All staff are expected to participate in the incident management process and
undertake training as relevant to their position.
Scope
This procedure applies to all staff of the Health Directorate, including contractors.
Procedure
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Two factors which relate to the entire incident management process are as follows:
Feedback and Communication
Feedback and communication of an incident relates to the entire process and is an
important mechanism to improve processes and prevent recurrence.
The success of incident management is dependent on communication to all staff during the
process in a timely manner. Staff involved in an incident need to be informed of the
recommendations arising from any investigation. These may be presented by their
manager/supervisor at staff meetings or via the Quality and Safety Officers at Divisional
Quality and Safety or Clinical Governance committees.
Generally, major and extreme outcome rated incidents will require a formal open disclosure
process. Incidents which are rated moderate or below require open communication using
the principles of open disclosure. The type of response is flexible and determined on a caseby-case basis. Please refer to the Significant Incident and Open Disclosure SOPs for more
information.
Documentation
Each step of the incident management process should be documented in the Riskman
incident notification and reporting module (Riskman). Documentation in Riskman should be
in the same manner as the Clinical Record. This provides a complete picture of what
happened and what was done to prevent the incident occurring again. For incidents
involving consumers, the incident should also be documented in the medical record with the
corresponding Riskman identification number. Managers are responsible for reviewing,
adding journal entries and finalising incidents reported by their staff in a timely manner.
Step 1: Identification
Staff who may identify an incident need to consider the following:
 The type of incident, e.g. worker injury, significant incident, harm to a consumer,
incidents reportable to Executive Director of Mental Health, Justice Health and
Alcohol and Drug Services.
 The immediate action required. This may include
i.
providing immediate care to individuals involved
ii.
making a situation/scene safe to prevent recurrence
iii. managing malfunctioning equipment
iv. gathering basic information to include in the Riskman report
v.
notifying supervisors/managers or security or the police
vi. apologising to the people involved if the incident is a result of treatment or
systems error - see Open Disclosure SOP for more information.
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Review Date
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Step 2: Notification
All incidents should be lodged in Riskman and documented in the clinical record. Incidents
should be lodged by 11.59pm the day following the incident. This includes near misses and
high risk incidents, even where there is no obvious outcome.
Note: If staff do not have access to Riskman, a telephone call can be made to the Riskman
Help Desk on Ph: (02) 6205 4000.
All identified hazards that have the potential to cause injury or illness to others should be
notified as “non-individual” incidents on Riskman.
Step 3: Classification
Incidents are initially classified by the reporter of the incident according to the severity of
the outcome, which is noted in the electronic Riskman report form. Attachment A outlines
how to rate incidents using categories, i.e., people, clinical (i.e. consumers), environment,
property and services, financial, information technology issues, business processes,
reputation and the environment. Under each category, examples are given to assist with the
rating process.
All incidents that are outcome rated Major or Extreme will require escalation. Significant
incidents require immediate senior clinical and executive notification and attention to
ensure that they are managed appropriately. Please refer to the Significant Incident SOP for
more information. If the incident is a result of a treatment or systems error or an
unexpected change in care, please refer to the Open Disclosure SOP.
Once an incident is lodged into Riskman by staff, Incident Classifiers may amend outcome
ratings and contributing factors as required and will review content for completeness and
accuracy. When an incident requires action from staff outside the notification source, the
classifiers will distribute appropriately. Incident Classifiers also provide Helpdesk support to
staff using Riskman to notify incidents (Ph: (02) 6205 4000).
Step 4: Investigation
Investigation methods of incidents may include aggregated data analysis, risk assessments,
interviews with staff/consumers/family members, review of policies and procedures and
clinical record reviews. The investigation method chosen should be determined by outcome
and the complexity of the incident.
The details of the investigation are to be entered into the Riskman incident reporting and
notification module by the appropriate staff member.
All staff incidents require appropriate recommendations and are tabled at the appropriate
committee, with reports to the Executive Directors every three months.
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Step 5: Action
Actions are developed and implemented following an investigation and should be developed
to prevent recurrence of an incident. Actions and follow-up need to be finalised by the
responsible manager on Riskman and any changes to local procedures documented
accordingly.
Step 6: Evaluation
Recommendations arising from incidents are to be implemented within an agreed timeframe
following the finalised investigation. When all recommendations are implemented and given
time to imbed into practice, the local area should evaluate the effectiveness of the
strategies. This is to ensure that:
 the systemic problems identified have been addressed
 recurrences have been reduced or eliminated
 lessons have been learned and communicated
 identified barriers to change have been removed
 systems are in place to ensure organisational learning.
A number of strategies can be used to evaluate the implementation, including a risk
assessment, monitoring of incident data for similar incidents and a “Look Back” process.
Special Circumstances
Incidents attracting media attention
Guidelines for what to do if approached by the media regarding an incident can be found in
the Health Directorate Media Policy.
Interagency incidents
Clinical incidents that involve both the care managed by the Health Directorate and by other
external agencies, including the ACT Ambulance Service and NSW Southern Local Health
District/Murrumbidgee Local Health District, will be referred to the Health Directorate
Health Interagency Clinical Review Committee (HICRC) for investigation. HICRC has
developed guidelines for the identification, reporting, notification and investigation of interagency clinical significant incidents.
Requests for Release of Information
Incident reports pertaining to consumers may be required to be disclosed to third parties.
For example, under the Civil Law (Wrongs) Act 2002 where a claim for damages for personal
injury is made, or under the discovery process where litigation has been commenced, the
consumer and their legal representative are entitled to receive documents which are
relevant. Documents such as clinical records and incident reports would be relevant and
accordingly may need to be provided. Similarly, incident reports are released under the
Freedom of Information Act 1982.
Any request for health records by patients/clients/consumers or third parties made through
the Medical Records Department or the Release of Information Coordinator in Mental
Health, Justice Health and Alcohol and Drug Services (MH, JH and ADS) activate release of
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corresponding incident notifications. This is done in line with the Release of Riskman Incident
Notifications SOP.
Calvary Health Care ACT
The governance arrangements in the Health Directorate are such that staff working in the
Mental Health, Justice Health and Alcohol and Drugs Service (MH, JH and ADS), Pathology
Division and Business and Infrastructure Branch may be working on the Calvary campus
although have reporting responsibilities to their respective division/branch. Any incident
reported on the Calvary campus is reviewed and investigated by staff from the Calvary
Quality, Safety & Risk Unit (QSR). Processes exist between the Quality and Safety Unit and
the Quality, Safety and Risk (QSR) Unit to facilitate reporting of Significant Incidents
occurring on the Calvary campus through Riskman and to notify each other of incidents
involving both organisations.
Note: The Brian Hennessy Rehabilitation Centre (BHRC), whilst in close vicinity to the Calvary
site is not part of the Calvary Campus. Incidents from BHRC are reviewed and investigated by
the Division of MH, JH and ADS. The Older Persons Mental Health Inpatient Unit (OPMHIU)
does however report through Calvary Health Care, therefore incidents are reviewed and
investigated by the QSR Unit, Calvary.
Evaluation
Outcome Measures
 100% of staff incidents have documented evidence of investigation in the Riskman
system and controls implemented 5 days post incident notification date.
 100% of incidents are notified by 11.59pm the day following the incident.
NB: Significant incident timeframes still apply as per the Significant Incidents SOP.
Method
 Reports are generated from Riskman and reported at the Work Health and Safety
Committee and the Divisional Quality and Safety Committees respectively.
Related Legislation, Policies and Standards
Legislation
o Health Act 1993 (ACT)
o Human Rights Act 2004 (ACT)
o Freedom of Information Act 1989
o Safety Rehabilitation and Compensation Act 1988
o Work Health and Safety Act 2011
o Work Health and Safety Regulation 2011
o Public Interest Disclosure Act 1994 (ACT)
o Work Health and Safety Codes of Practice
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Standards
o ACHS EQuIP 5, Support, Criteria 2.1.2 & 2.1.3
o Australian Commission on Safety and Quality in Healthcare – National Safety and
Quality Health Service Standards
o Open Disclosure Standard: a National Standard for Open Communication in Public
and Private Hospitals, Following an Adverse Event in Health Care 2003 (under
review)
o Risk Management Standard (ISO 31000:2009)
o Australian Charter of Healthcare Rights
Policies
o
o
o
o
o
o
o
o
o
o
o
o
Health Directorate “Consumer Feedback Management” Policy and SOP
Health Directorate “Risk Management Policy”, Standard Operating Procedure and
Guidelines (under review)
ACT Health Clinical Review Process Framework (2008) (under review)
Little Company of Mary Health Care, Significant Events Policy
Little Company of Mary Health Care, Clinical Governance Framework
Little Company of Mary Health Care. Incident, Accident and Near Miss
Health Directorate Records Management Policy
Employees Assistance Program Policy
Preventing and Managing Aggression and Violence Policy
Health Directorate Public Interest Disclosure Policy (under review)
Mental Health, Justice Health and Alcohol and Drug Services policy: “Incidents
Reportable to the Director of Mental Health” (under review)
Health Directorate Safety Management System (under review)
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Definition of Terms (only use this section if needed, delete if not needed)
Adverse event
an incident in which harm resulted to a person receiving health care.
Dangerous incident
any incident in relation to a workplace that exposes a worker or any
other person to a serious risk to a person's health or safety emanating
from an immediate or imminent exposure to:

an uncontrolled escape, spillage or leakage of a substance

an uncontrolled implosion, explosion or fire

an uncontrolled escape of gas or steam

an uncontrolled escape of a pressurised substance

electric shock

the fall or release from a height of any plant*, substance or thing

the collapse, overturning, failure or malfunction of, or damage to
any plant that is required to be authorised for use in the
regulations

the collapse or partial collapse of a structure

the collapse or failure of an evacuation or of any shoring
supporting an excavation

the inrush of water, mud or gas in workings, in an underground
excavation or tunnel

the interruption of the main system of ventilation in an
underground excavation or tunnel or

another event prescribed in the regulations.
A dangerous incident can also be referred to as a Significant Incident
and/or a Notifiable Incident. *See definition of “plant” below.
Hazard
a circumstance or agent that can lead to harm, damage or loss.
High risk incident
any event that would have resulted in a significant incident should it
have eventuated (also referred to as a significant near miss), incidents
that could attract significant media attention and possible significant
incidents where the status is unclear until further investigation is
undertaken.
Incident
An event or circumstance which could have resulted in, or did result,
in unintended or unnecessary:

harm
o to a worker
o to a patient/client/consumer

complaint, loss or damage
o to property and services (including infrastructure)
o to the environment
o regarding financial management
o regarding information management
o regarding the reputation of the organisation

deviations
o from endorsed plans/processes.
Look Back
a standardised process that is triggered when a notification of a
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clinical incident, or concern, from any source leads to the need for
the notification, investigation and the management of a group of
commonly affected consumers. The clinical incident may arise from
complications or errors relating to diagnostics, treatment or products
that consumers have received.
Near miss
An incident that did not cause harm
Notifiable incident
(staff)
an incident which occurs to a staff member and requires immediate
notification to the Workplace Safety Section of the Quality and Safety
Unit and WorkSafe ACT. It includes:
a) The death of a staff member or
b) A serious injury or illness of a staff member or
c) A dangerous incident (also see definition)
A notifiable incident can also be referred to as a Significant Incident.
Open disclosure
is a process of communication with consumers following an adverse
event and is not a legal process. Apologising and disclosing an
adverse event to a consumer is not the same as admitting fault,
rather it is an expression of regret and statements of fact. The
standard outlines a clear and consistent process which includes:

an apology

an invitation for the consumer to relay their perspective on the
event

a factual explanation of what occurred, including actual and
potential consequences, and

the steps being taken to manage the event and prevent its
recurrence
Refer to the Open Disclosure SOP for more information.
Outcome rating
see Appendix A of the Incident Management SOP
Plant (related to a
dangerous incident)
Includes any machinery, equipment, appliance, container, implement
and tool or anything fitted or connected to machinery, equipment,
appliance, container, implement or a tool.
Riskman
An online web based system used to report incidents
Sentinel events
The Australian Commission for Safety and Quality in Health Care has
worked closely with all jurisdictions to develop a national core set of
sentinel events. The agreed national list of core sentinel events
consists of:

Procedures involving the wrong patient or body part resulting in
death or permanent loss of function

Suicide of a patient in an inpatient unit

Retained instruments or other material after surgery requiring
re-operation or further surgical procedure

Intravascular gas embolism resulting in death or neurological
damage

Haemolytic blood transfusion reaction resulting from ABO
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incompatibility
Medication error leading to the death of patient reasonably
believed to be due to incorrect administration of drugs

Maternal death or serious morbidity associated with labour or
delivery

Infant discharged to the wrong family.
A sentinel event can also be referred to as a Significant Incident.

Significant Incident
an incident with an Extreme or Major outcome occurring in relation
to Health Directorate services and care, requiring immediate
notification to the Director General/Deputy Director General.
Significant Incidents include Sentinel events and Notifiable Incidents.
Work Injury
an injury or illness contracted as a result of duties performed during
the course or work activities.
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References
Australian Commission on Safety and Quality in Healthcare 2008; National Safety and
Quality Health Service Standards, Commonwealth of Australia.
NSW Health 2007, Incident Management Policy Directive, Department of Health, NSW.
Queensland Health 2009, Clinical Incident Management Implementation Standard (CIMIS),
Queensland Government, Queensland.
Government of Western Australia Department of Health 2011; Clinical Incident Management
Policy; Western Australian Department of Health, Western Australia.
Attachments
A – Outcome rating table
B – Incident Management Flowchart
Disclaimer: This document has been developed by Health Directorate, <Name of Division/ Branch/Unit>
specifically for its own use. Use of this document and any reliance on the information contained therein by any
third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.
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Appendix A
Outcome Rating Table
Insignificant
People
(Staff, Contractors,
Visitors, students)
Injuries or ailments
related to a
workplace incident
not requiring
medical treatment
No injury
No review required
Clinical
(patient, client,
consumer related)
No increased level
of care
Minor
Moderate
First aid treatment
Lost time and/or injury to
1 or more
workers/visitors related
to a workplace incident
No lost time or
restricted duties
related to a
workplace incident
Medical expenses or
restricted duties related
to a workplace incident
Minor injury
requiring:
o Review and
evaluation
o Additional
observations
o First aid treatment
Temporary loss of
function (sensory, motor,
physiologic or
intellectual) unrelated to
the natural course of the
underlying illness and
differing from the
expected outcome of
patient management.
Incident resulting in
transfer to higher level of
care or additional
procedure.
No loss of service
Property and
Services
(Business services
and continuity)
Event that may
have resulted in the
disruption of
services but did not
on this occasion.
Information
Reduced efficiency or
disruption of some
aspects of an
essential service.
Disruption to one service
or department for 4 to 24
hours - managed by
alternative routine
procedures
Cancellation of
appointments or
admissions for a number
of patients
Extreme/Catastrophic
Significant Incident
Significant incident
A hostage situation
Death of a worker/visitor
following a workplace incident
Three or more staff requiring time off
following an adverse event
Major and permanent loss of function
(sensory, motor, physiological or
intellectual) unrelated to the natural
course of the underlying illness and
differing from the expected outcome
of patient management.
# Hysterectomy as an emergency
procedure following childbirth will be
assessed on a case by case basis
through clinical review process for
outcome rating.
Patient death unrelated to the
natural course of the underlying
illness and differing from the
immediate expected outcome of
patient management.
Death of a client in custody
(under MH order (e.g. EA, ED3,
ED7 or PTO) or police custody)
All national core sentinel events
(see definition of terms)
Major damage to one or more
services or departments affecting the
whole facility – unable to be managed
by alternative routine procedures.
Loss of an essential service
resulting in shut down of a
service unit or facility
Service evacuation causing major
disruption of greater than 24 hours,
e.g. Fire/ flood requiring evacuation
of workers/visitors and
patients/clients (no injury)
Disaster plan activation
Bomb threat procedure activation,
potential bomb identified, partial or
full evacuation required (+/- injury)
Destruction or damage to
property requiring significant
unbudgeted expenditure
Destruction or
damage to property
requiring some
unbudgeted
expenditure
Cancellation of surgery or
procedure more than
twice for one patient
Destruction or damage to
property requiring minor
unbudgeted expenditure
Loss of 1% of
budget or <$50K
Loss of 2.5% of
budget or between
$50 -$1M
Loss of 5% of budget or
between $5 -$10M
Loss of 10% of budget or between
$10M - $200M
Loss of 25% of budget or
between $200M - $500M
Interruption to
records / data
access less than ½
day
Interruption to
records / data access
½ to 1day
Significant interruption
(but not permanent loss)
to data / records access,
lasting 1 day to 1 week
Complete, permanent loss of some
ACT Health or Division/Business
Unit/Service records and / or data, or
loss of access greater than 1 week.
Complete, permanent loss of all
ACT Health or divisional/service
records and data.
Event that may
have resulted in the
mishandling of
clinical records
Inappropriate
storage of clinical
records in a
department
Inappropriate storage of
clinical records in the
facility
Inappropriate storage or exposure of
patient/client consumer or clinical
records in a public area +/- breach in
patient privacy and confidentiality.
(These will be assessed on a case by
case basis.)
Minimal or no
destruction or
damage to property
Financial
Closure or disruption
of a service for less
than 4 hoursmanaged by
alternative routine
procedures.
Major
Destruction or damage of property
requiring major unbudgeted
expenditure
Inappropriate destruction of
patient/client/consumer clinical
records by a worker
Business Process
and Systems
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Minor errors in
systems or
processes requiring
corrective action, or
Issued
October 2012
Policy procedural
rule
occasionally not met
or services do not
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One or more key
accountability
requirements not met.
Inconvenient but not
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Strategies not consistent with Health
Directorate and Government’s
agenda. Trends show service is
degraded
Critical system failure, bad
policy advice or ongoing noncompliance. Business severely
affected.
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Insignificant
Reputation
Environment
Broadly defined as
the surroundings in
which ACT Health
operates, including
air, water, land,
natural resources,
flora, fauna, humans
and their
interrelation.
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Minor
Moderate
Major
Extreme/Catastrophic
Significant Incident
Significant incident
minor delay without
impact on overall
schedule.
fully meet needs.
client welfare
threatening.
Claims made by the
media that have an
insignificant impact
on community
perception of the
organisation
Claims made by the
media that have a
minor impact on
community
perception of the
organisation
Claims made by the
media that have a
moderate impact on
community perception of
the organisation
Claims made by the media that have
a major impact on community
perception of the organisation
Claims made by the media that
have an extreme impact on
community perception of the
organisation
Near miss release of
Chemical, Biological
or Radiological or
other toxic agent.
Limited spillage/
release of Chemical,
Biological
Radiological or other
toxic agent contained
and cleaned up with
no evacuation and no
external assistance
required
Chemical, Biological or
radiological release
contained without
external assistance
Toxic release (i.e. chemical, biological,
radiological) requiring assistance of
emergency services with no
detrimental affect
Toxic release (i.e. chemical,
biological or radiological) with
detrimental effect on
environment and/or personnel
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Incident Management Flowchart
1. Identification
DOCUMENT
Ring Riskman Help Desk
Ph: 6205 4000 if requiring
assistance or no computer access
The incident in the
Clinical Record if
consumer incident
Incident or near miss occurs
Notify immediate superior
Serious incident: consult
Significant Incident SOP
DOCUMENT
2. Notification
Consumer harm: Consult
Open Disclosure SOP
Complete Riskman
report
Notify supervisor/manager
Distribute Riskman incident as appropriate
Serious work injury: Notify WorkSafe ACT if a notifiable incident
Serious consumer incident: If after hours notify on-call Executive Director; and
Notify appropriate Clinical Lead
3. Classification
Work injury: consult Safety
Management System
DOCUMENT
Staff provide an initial outcome rating using the table above.
Classifiers amend as required.
Staff
Accident/Incident
Report if staff incident
DOCUMENT
4. Investigation
Update Riskman
fields as appropriate
Discuss with team members
Review clinical records
Interview staff and consumers
Determine sequence of events
Ask: what happened? What should have happened? Focus on processes
Decide on strategies to prevent the incident happening again
5. Action
DOCUMENT
Update Riskman
fields as appropriate
Notify team members as to change in practice
Follow up with consumers and staff who were involved as appropriate
Determine if any quality improvement activities need to be initiated
Finalise any clinical review processes
Check if any other areas in the Health Directorate need notifying of a change in practice
6. Evaluation
DOCUMENT
Monitor service provision areas related to the incident for any further incidents
Analyse Riskman data
Update Policies and SOPS
Conduct a Risk/Hazard Assessment if required
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Update Riskman
fields as appropriate