Clinical incident management – Purpose and principles

A clinical incident is an event or circumstance resulting from health care provision (or lack thereof) which could have or did lead to unintended or unnecessary physical or psychological harm to a patient.

The purpose of clinical incident management is to ensure implementation of consistent and accountable processes and systems for the management of clinical incidents with the goal to prevent harm to patients and improve patient safety. It is based on the following principles:

Principle Description
Transparency Full and open communication is to occur as part of clinical incident management. As appropriate, patients, staff and visitors notifying clinical incidents will receive feedback on findings of any investigation and preventative actions carried out.
Accountability Services have a duty to take reasonable care to avoid harm to patients, staff and visitors. Individuals understand they may be held accountable for their actions.
Probity/fairness Staff and patients involved in clinical incidents will be entitled to fair treatment. Analysis of an incident should focus on ‘what happened?’, ‘why did it happen?’ and ‘how could it be prevented from occurring again?’ Implementation and evaluation of recommendations is essential.
Patient centred care The patient, their family and carers who are associated with the incident are asked to contribute to the CIM process as appropriate, particularly during the investigation. Outcomes of an investigation are to be shared and communicated openly.

Open 'just' culture

The focus of an analysis and investigation of clinical incidents focuses on identifying and correcting underlying system problems rather than focusing on an individual. The workforce is supported when systems break down and errors occur.
Obligation to act The responsibility to take action to correct problems is clearly accepted.
Prioritisation Resources are directed to areas where improvements to prevent harm are possible. It must also be directed to the areas of high clinical risk.

The Clinical Incident Management Policy promotes best practices in clinical incident management 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.

Watch these videos on the purpose of clinical incident management (external site) and the clinical incident management process (external site) presented by Dr Matthew Thomas.

CIM Policy Pack – Resources

It is vital that health staff are free to notify and participate in clinical incident investigations without fear of retribution. For an explanation of Medical Indemnity in Clinical Incident Management, see the just culture page.

Severity assessment codes

Before an investigation of the clinical incident can take place, a severity assessment code (SAC) rating must be confirmed and allocated which will determine the prioritisation of the clinical incident investigation.

There are three WA health system Severity Assessment Codes (SAC), which must be used:

  • SAC 1 – A clinical incident that has or could have (near miss), caused serious harm or death; and which is attributed to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.
  • SAC 2 – A clinical incident that has or could have (near miss), caused moderate harm; and which is attributed to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.
  • SAC 3 – A clinical incident that has or could have (near miss) caused minor or no harm; and which is attributed to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.

Multi-site clinical incidents

In complex health systems it is common for care to be provided across multiple sites or occasionally by multiple agencies. In this scenario a clinical incident may be identified at one site where the patient outcome becomes known, but the clinical incident may have occurred at other sites or in the transition or communication between sites. It is important to identify contributing factors at each stage of the patient journey to prevent similar events from reoccurring. An investigation into a clinical incident which involves more than one site or health care service is considered a multi-site investigation. The Guideline for the Investigation of Multi-site clinical incidents provides a framework for sites and services to engage in multi-site clinical incident investigations. This Guideline should be read in conjunction with the CIM Policy Pack resources.

SAC 1 clinical incident investigations - Roles and responsibilities

The PSSU has developed a state-wide resource to provide guidance about roles and responsibilities in the SAC 1 investigation process. This guidance is intended to provide core information that HSPs and private healthcare providers can tailor to their local context to assist staff involved in SAC 1 incidents and investigations about the attributes of effective clinical incident investigation processes, and their roles and responsibilities within the process. It should be used in conjunction with the CIM Policy, Guideline and Toolkit, and the Guideline for the Investigation of Multi-Site clinical incidents.

Clinical incident management and contracted health entities

A contracted health entity (CHE) is a non-government entity that provides health services to Western Australians under a contract or agreement with the Department of Health, a health service provider or the Minister for Health.

For CHEs, clinical governance includes their contract with the WA health system and the relationship with their contract manager. Clinical incident management is one important element of clinical governance however the CIM Policy only applies to CHEs to the extent described in their contract. Therefore, it is important that these contracts clearly state which CIM Policy requirements apply and how the CHE is expected to comply with them.

The information sheet Clinical Incident Management and Contracted Health Entities sets out key aspects of CIM principles and processes in WA as they may apply CHEs. While designed to assist procurement and contract management teams in developing and supporting contracts with appropriate and robust CIM requirements, this information may also be useful for CHEs.

Consumers in clinical incident management

At the centre of every clinical incident is a health care consumer. When a consumer is harmed in the health system the open disclosure process should be followed. Open Disclosure is the open discussion of incidents that result in harm to a patient while receiving health care with the patient, their family, carers and other support persons. The elements of open disclosure are an apology or expression of regret (including the word ‘sorry’), a factual explanation of what happened, an opportunity for the patient to relate their experience, and an explanation of the steps being taken to manage the event and prevent recurrence.

The PSSU has developed a state-wide resource to provide information for health consumers about the SAC 1 investigation process. This resource is intended to provide core information that health services can tailor to their local context to assist health consumers, their families and carers that are affected by serious clinical incidents and the investigations that follow.

  1. After a serious clinical incident – print version (PDF 1.8MB)
  2. After a serious clinical incident – e-form (PDF 402KB)

If following the completion of a clinical incident investigation a consumer remains unsatisfied with the outcome a complaint can be made via the site’s complaint management process. Consumers may also identify issues via the complaint management process that are subsequently identified and investigated as a clinical incident.

Videos on the consumers’ perspective in incident investigation (external site) and involving patients and family in incident investigation (external site) further describe the relation of consumers to the clinical incident management process.

More information

Patient Safety and Surveillance Unit

Last reviewed: 08-04-2022
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Patient Safety Surveillance Unit