Clinical incidents

Sometimes, despite our best intentions, clinical incidents can occur. When that occurs, we report and review each case to understand what happened so that we can learn from it and reduce the likelihood of it happening again.

In healthcare, we think beyond the patient or the treating doctor. We think about the environment in which the patient received care and if this could be improved. We call this systems thinking. If we identify an issue in this broader system, we call the adverse outcome a clinical incident.

We collect information about clinical incidents so that we can improve the care we provide to our patients.

To help us do this, we categorise clinical incidents by the severity of the impact of the event on patients. Clinical incidents are categorised by their Severity Assessment Codes (SAC).

SAC1

SAC1 incidents are associated with a patient outcome or potential outcome of serious harm or death. These incidents are rare.

SAC2

SAC2 incidents have a patient outcome of moderate harm.

SAC3

SAC3 incidents result in no or minimal harm and are the majority of incidents that occur.

Sentinel events

Sentinel events: a subset of SAC1 incidents which are preventable and result in serious harm to, or death of, a patient. All Australian states and territories report these.

Because we want the best outcomes possible for our patients, we count and review even those incidents where no harm occurred.  Some people call these near misses or good catches.

Health is more than physical. In our clinical incident work, we think about psychological harm as well as physical harm.

We aim for low levels of SAC1 incidents where harm occurred and in Western Australia these incidents are rare. High rates of SAC2 and SAC3 incidents indicate a good reporting culture, demonstrating our strong and proactive approach to patient safety.

We have reported the number of clinical incidents by their severity for each financial year. To provide context, we have also reported clinical incidents that occurred in inpatient settings as the rate of clinical incidents per 10,000 patient days.

For further details about all clinical incidents, please refer to annual reports published by individual Health Service Providers.