Clinical Risk Reporting Process

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					                                   Clinical Risk Reporting Process
                                                                                        Start




          Incident identified                                            Is the event an incident?
  First step - ensure pt is safe                                  An incident is "any event that has caused harm,
  Second step - incident form completed by:                                                                                        Continue care as
      identifying clinican
                                                    Yes           or has the potential to harm a pt or visitor, for any       No
                                                                     event which involves malfunction, or loss of                     planned
      medical staff - where appropriate                            equipment or property, and for any event which
      senior staff member at the time                                         might lead to a complaint"




    Is the event a Sentinel Event?
    Sentinel Events are:
    1. Procedures involving the wrong patient or body part
    2. Intravascular gas embolism resulting in serious neurological
    damage or mortality                                                                               Notify:
    3. Haemolytic blood transfusion resulting from ABO incompatibility
                                                                                                      W ithin business hours
    4. Patient suicide in hospital *
                                                                                                      Clinical Incident M anager
    5. Retained instrument or other material after surgery, requiring
                                                                                                         Ext/pgr: 5058
    re-operation or further surgical procedure                                          Yes              Email: sarah.callaghan
     6. M edical error leading to the death of a patient reasonably
                                                                                                      Outside business hours
    believed to be due to incorrect administration of drugs
                                                                                                      Nursing Supervisor
    7. M aternal death or serious disability associated with labour or
                                                                                                         Ext/pgr: 4000
    delivery
    8. Infant discharged to wrong family
    9. Other
    *Episodes of suicide that are reportable under the M ental Health Act
    (1986) should continue to be reported to the Chief Psychiatrist.                                                               Send Incident form to
                                                                                                                                    Clinical Manager
                                                                                                                                     eg NUM or HOD
                                     No




                                                                                                         Notify:
                                                                                                         Annie M oulden
                                                                                                           Ext: 6957
                Is the event an Adverse Event?
                                                                                                           Email: annie.moulden
                An adverse event is an unintended injury or                                              OR
                complication which results in disability, death                   Yes                    Karen Dunn
                or prolonged hospital stay and is caused by                                                Ext: 6957
                health care management rather than the                                                     Email: karen.dunn
                disease process                                                                          OR
                                                                                                         Ed Oakley
                                                                                                           Ext: 6593
                                                                                                                                   Clinical Manager
                                     No




                                                                                                           Email: ed.oakley
                                                                                                                                   eg NUM or HOD sends
                                                                                                                                   Incident form to the
              Send Incident form to Clinical Manager                                                                               Clinical Incident
                         eg NUM or HOD                                                                                             Manager in CSS



Sarah Callaghan is available for notification & discussion of all Incidents & Sentinel Events                                        Continue Over
     Continued
                                                        What happens next?

                    Incident                                             Sentinel Event                                          Adverse Event


         Collection and investigation of incident             Notifcation to the DHS within 15 days of the event     T he focus of the adverse event review is to examine
               reports with staff feedback                                        occuring                           the systems in which the event occcurred to develop
                                                                                                                      mechanisms for reducing or removing the potential
                                                                                                                                for a similar event in the future


Medication Incidents            Non-medication Incidents
           .                                  .               T he Sentinel Events Committee, a subcommittee of
                                Discussed with Director of    the Pt Safety Committee completes a "Root Cause
Discussed at Medication          CSS & Clinical Incident       Analysis" (an assessment tool as to the why's and     After an adverse event is identified, feedback is sought
   Safety Committee             Manager & tabled at Patient   how's) and reports within 45 working days to the DHS   from staff involved in the case and it is then discussed
                                    Safety Committee                                                                                at the Pt Safety Committee




        Recommendations are made and the relevant               Recommendations are made and the relevant               Recommendations are made and the relevant
         areas informed of actions and improvements              areas informed of actions and improvements              areas informed of actions and improvements
         identified for implementation and evaluation            identified for implementation and evaluation            identified for implementation and evaluation




                                                                  Report to Quality and Safety Committee             Report to Quality and Safety Committeeommittee
          Report to Quality and Safety Committee



                                                                                                                                                         Thank-you