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Quality and Safety
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Easy Guide to Clinical Incident Management
Key principles of open disclosure
- openness and timeliness of communication
- acknowledgement of error
- expression of regret
- recognition of the reasonable expectations
of patients and their support persons
- support for health staff
- confidentiality.
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An apology does not...
- blame the health facility for harm
caused to the patient
- blame a clinician for harm caused
to the patient
- blame the Health Service for harm
caused to the patient
- indicate that the adverse event could
have been avoided.
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>> print version
Step 7. Feedback
Covered in this page are Feedback
to patients | Feedback to staff
| Supporting staff |
Being error wise | Sharing Lessons
learned
Feedback to patients
Irrespective of the level of response to an incident,
the patient must be fully informed within 24 hours
of acknowledgement of the incident. At the first meeting
with the patient and carer, you should provide:
- an explanation of what happened, the immediate
effects, and prognosis
- an apology
- the contact names and phone numbers of
people in the health facility who are available
to address concerns and complaints, including psychological
and social support contacts.
What can and can't be disclosed
Part of the investigation process involves identifying
documents and other communications that can be released
to the patient and support person. If an individual
performance issue has been identified, the course of
action is redirected to your organisation’s performance
management system, as stated in Complaint
or Concern about a Clinician – Principles for Action
PD2006_007.
The following restrictions prevent the release of
information to the patient, in some circumstances:
- The final RCA report arising from SAC 1 incidents
is the only document that can be used to provide feedback
on a SAC 1 incident. However, the patient's clinical
record and other documents that were not part
of the RCA team's process can also be used to provide
feedback to patients and support persons.
- Special Privilege under section 23 of the
Health Administration Act 1982
Documents prepared for, or on behalf or, the Reportable
Incident Review Committee (RIRC), including the
Clinical Reportable Incident Briefs (RIBS) are protected
by special privilege.
- Insurance contractual arrangements
Insurance contracts with the MDOs and the TMF may
preclude disclosure of specific information that
may be protected. In these cases, the patient will
be informed of the reasons for the restriction.
- Statutory Privilege under Division 6C of
the Health Administration Act 1982
Documents that are created by an RCA team during
an RCA investigation are protected by statutory
privilege. This information cannot be disclosed
or subpoenaed by a court, and the RCA team is not
bound to give evidence about the RCA before a court
or tribunal. The causation statements in the final
RCA report can be disclosed.
- Client Legal Privilege
Client legal privilege can protect certain documents
from being disclosed. Any oral or written statement
or other material, which has been created solely
for the purpose of advice or use in litigation (for
example, between a patient and a lawyer), remains
confidential and cannot be revealed to a third party.
- Pending Coronial Findings
The patient and support person should be informed
of the reasons why coronial findings are restricted.
If you are a manager...
... present the findings of the incident investigation
and analysis at team meetings. Regularly produce
and discuss incident reports on a regular basis.
This assists in sustaining improvements. In the
complex environment of health care delivery, it
is important that clinicians maintain "informed
vigilance". Passing on inforamtion to staff
makes them error wise.
Use IIMS reports...
... to develop incident reduction programs at
the local level.
Monitor regularly...
... to evaluate the effectiveness of actions taken
to reduce incidents. Monitoring involves activities
such as:
- audits
- patient feedback surveys and focus groups
- comparing performance against indicators,
such as the Australian Care Standards (ACHS),
or locally developed indicators.
Results of monitoring should be fed back to
staff.
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Feedback to staff
If you are a notifier and entered details in IIMS...
... you will receive feedback on the results of the
investigation and actions for improvement. For a clinical
SAC1, the feedback is based on the final RCA report.
If you were involved in the incident...
... you will receive feedback as a member of the team.
It is good practice to reflect on the incident from both
a team and individual perspective by asking "What
can I and we do to prevent this incident from happening
again?"
Being error wise means...
- accepting that errors can and will occur
- assessing the local environment, resources and
your own ability before commencing tasks and procedures
- having contingencies ready to deal with anticipated
problems
- being prepared to seek more qualified assistance
- overcoming professional courtesy and checking
colleagues' knowledge and expertise
- appreciating that the path to incidents is paved
with false assumptions.
Sharing lessons learned
Information arising from lessons learned should be shared,
and successful improvements should be spread throughout
the NSW health system. This can be achieved through team
meetings, newsletters and other communication strategies.
The Quality and Safety Branch have developed a Lessons
Learned in Quality and Safety website (Intranet
only), and you are encouraged to submit and discuss your
case studies.
Supporting staff
Staff involved in an incident should be offered
an appropriate level of support. The effect on involved
staff can be profound. The literature identifies that
they "may experience shame, guilt and/or depression".
They may also feel cut off by their colleagues, so the
support of colleagues is important. The openness of senior
clinicians about errors and their frequency is an effective
strategy when dealing with junior staff.
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