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Standard Operating Procedure

Incident Management
Purpose
The incident management system provides a step by step process for staf
to follow when an incident occurs. All staf are expected to participate in
the incident management process and undertake training as relevant to
their position.
Scope
This procedure applies to all staf 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 staf during the process in a timely manner. Staf involved in an incident
need to be informed of the recommendations arising from any
investigation. These may be presented by their manager/supervisor at
staf 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 case-by-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 staf in a timely manner.
Step 1: Identification
Staf 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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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 staf 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 staf, 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 staf outside the notification source, the classifiers will
distribute appropriately. Incident Classifiers also provide Helpdesk support
to staf 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 staf/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 staf member.
All staf 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 efectiveness 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 inter-agency 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.

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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 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 staf
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 staf 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 staf 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
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o
o
o
o

Work Health and Safety Act 2011

Work Health and Safety Regulation 2011
Public Interest Disclosure Act 1994 (ACT)
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 Health Directorate Consumer Feedback Management Policy and
SOP
o Health Directorate Risk Management Policy, Standard Operating
Procedure and Guidelines (under review)
o ACT Health Clinical Review Process Framework (2008) (under
review)
o Little Company of Mary Health Care, Significant Events Policy
o Little Company of Mary Health Care, Clinical Governance
Framework
o Little Company of Mary Health Care. Incident, Accident and Near
Miss
o Health Directorate Records Management Policy
o Employees Assistance Program Policy
o Preventing and Managing Aggression and Violence Policy
o Health Directorate Public Interest Disclosure Policy (under review)
o Mental Health, Justice Health and Alcohol and Drug Services
policy: Incidents Reportable to the Director of Mental Health
(under review)
o 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.

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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 clinical incident, or concern, from any
source leads to the need for the notification,
investigation and the management of a group of
commonly afected 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 (staf)

an incident which occurs to a staf 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 staf member or
b) A serious injury or illness of a staf 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.

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Outcome
rating
Plant (related
to a
dangerous
incident)

see Appendix A of the Incident Management SOP

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 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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Includes any machinery, equipment, appliance,

container, implement and tool or anything fitted or
connected to machinery, equipment, appliance,
container, implement or a tool.

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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
(Staf,
Contractors,
Visitors,
students)

Moderate

Injuries or
ailments related
to a workplace
incident not
requiring
medical
treatment

First aid
treatment

No lost time or
restricted duties
related to a
workplace
incident

Medical expenses or
restricted duties
related to a
workplace incident

No injury

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 difering
from the expected
outcome of patient
management.

No review
required

Clinical
(patient, client,
consumer
related)

Minor

No increased
level of care

Lost time and/or

injury to 1 or more
workers/visitors
related to a
workplace incident

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.
Minimal or no
destruction or
damage to
property

Financial
Information

Closure or
disruption of a
service for less
than 4 hoursmanaged by
alternative
routine
procedures.
Reduced
efficiency or
disruption of
some aspects of
an essential
service.

Destruction or
damage to
property
requiring some
unbudgeted
expenditure

Major

Extreme/Catastrophic

Significant Incident

Significant incident

A hostage situation
Three or more staf requiring
time of 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 difering 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.

Disruption to one
service or
department for 4 to
24 hours - managed
by alternative
routine procedures

Major damage to one or more

services or departments
afecting the whole facility
unable to be managed by
alternative routine
procedures.

Cancellation of
appointments or
admissions for a
number of patients

Service evacuation causing

major disruption of greater
than 24 hours, e.g. Fire/ flood
requiring evacuation of
workers/visitors and
patients/clients (no injury)

Cancellation of
surgery or
procedure more
than twice for one
patient
Destruction or
damage to property
requiring minor
unbudgeted
expenditure

Bomb threat procedure

activation, potential bomb
identified, partial or full
evacuation required (+/injury)

Death of a worker/visitor
following a workplace
incident

Patient death unrelated to

the natural course of the
underlying illness and
difering 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)

Loss of an essential
service resulting in shut
down of a service unit or
facility

Disaster plan activation

Destruction or damage to
property requiring
significant unbudgeted
expenditure

Destruction or damage of
property requiring major
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
day

Interruption to
records / data
access to 1day

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

Significant
interruption (but not
permanent loss) to
data / records
access, lasting 1
day to 1 week
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

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Insignificant

Minor

Moderate

Major

Extreme/Catastrophic

Significant Incident

Significant incident

assessed on a case by case

basis.)

Business
Process and
Systems

Reputation

Environment
Broadly defined
as the
surroundings in
which ACT
Health operates,
including air,
water, land,
natural
resources, flora,
fauna, humans
and their
interrelation.

Inappropriate destruction of
patient/client/consumer
clinical records by a worker
Strategies not consistent with
Health Directorate and
Governments agenda. Trends
show service is degraded

Minor errors in
systems or
processes
requiring
corrective
action, or minor
delay without
impact on
overall
schedule.

Policy procedural
rule
occasionally not
met or services
do not fully meet
needs.

One or more key

accountability
requirements not
met.
Inconvenient but not
client welfare
threatening.

Critical system failure, bad

policy advice or ongoing
non-compliance. Business
severely afected.

Claims made by
the media that
have an
insignificant
impact on
community
perception of
the organisation
Near miss
release of
Chemical,
Biological or
Radiological or
other toxic
agent.

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

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 afect

Toxic release (i.e.

chemical, biological or
radiological) with
detrimental efect on
environment and/or
personnel

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Incident Management Flowchart

1. Identification
Incident or near miss occurs
Notify immediate superior

DOCUMENT

Ring Riskman Help Desk

Ph: 6205 4000 if requiring
assistance or no computer access

The incident in the

Clinical Record if
consumer incident

Serious incident: consult

Significant Incident SOP

Notify supervisor/manager
Distribute Riskman incident as appropriate
DOCUMENT
2. Notification Serious work injury: Notify WorkSafe ACT if a notifiableComplete
Riskman
incident
report
Serious consumer incident: If after hours notify on-call Executive Director; and
Notify appropriate Clinical Lead

Consumer harm: Consult

Open Disclosure SOP

Work injury: consult Safety

Management System

3. Classification
Staff provide an initial outcome rating using the table above.
Classifiers amend as required.

4. Investigation

DOCUMENT
Staff Accident/Incident
Report if staff incident

DOCUMENT
Update Riskman fields
as appropriate

5. Action

DOCUMENT
Update Riskman fields
as appropriate

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

Update Riskman fields

as appropriate