Clinical Incident Management Policy 2019

Applicable to: This Policy is applicable to all Health Service Providers and Contracted Health Entities to the extent that this Policy forms part of their contract.

Description: On 1 November 2019, an updated Clinical Incident Management (CIM) Policy was endorsed by the Director General.

The purpose of the Clinical Incident Management (CIM) Policy is to ensure Health Service Providers implement consistent and accountable processes and systems for the management of clinical incidents with the goal to prevent harm to patients and improve patient safety.

The Policy promotes best practices in CIM to:

  1. Identify when patients are harmed and implement strategies to minimise harm.
  2. Ensure lessons are learned; provide opportunities to share lessons and take action to reduce the risk of similar events occurring.
  3. Identify hazards before they cause patient harm, treat the hazard and review clinical risks.

The CIM Policy is also part of the assurance mechanisms supporting the Department CEO in fulfilling their functions of overseeing and monitoring the safety and quality of services provided by Health Service Providers in Western Australia.

The Policy also supports the WA health system to report on sentinel events to the Commonwealth. On behalf of the WA health system, the Department reports this clinical incident data. Further, episodes of care which include sentinel events are also required to be reported to the Independent Hospital Pricing Authority (IHPA) for funding purposes.

This Policy is a mandatory requirement under the Clinical Governance, Safety and Quality Policy Framework pursuant to section 26(2) (a), (c) and (d) of the Health Services Act 2016. This Policy supersedes Operational Directive 0611/15 Clinical Incident Management Policy (Revised April 2018).

Incidents not within the scope of this Policy include suspected staff misconduct, occupational safety and health incidents that involve staff or incidents involving visitors unrelated to the provision of a health care service to a patient. The management of clinical incidents, particularly the investigation process must not be used as a method to investigate staff misconduct.

The following documents inform and support the implementation of the CIM Policy -

  • Clinical Incident Management Guideline 2019 - supporting information which provides supplementary information to assist services in meeting the Policy requirements.
  • Clinical Incident Management Toolkit 2019 - supporting information which provide a further range of patient safety and incident management literature.

Date of effect: 01 November 2019

Policy Framework

Supporting information