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Easy Guide to Clinical Incident Management - Step 1. Identification

Easy Guide to Clinical Incident Management - Step 1. Identification

Often, we accept incidents because we see them as being a normal part of the day. A patient slips while going to the toilet and is not harmed, or develops a known complication following surgery; or the wrong medication is given with no adverse outcome. These events are all incidents and must be notified.

There are two types of identification: direct observation and indirect observation.

Direct observation

You saw it happen (or almost happen), or you made (or almost made) the error yourself. Take immediate steps to care for the people involved and ensure that safety issues are addressed.

Indirect observation

You heard about the incident or discovered the error later through:

direct notification
death audit
medical record audit
surveillance
peer review
morbidity and mortality meetings
NSW Coroner
complaints
external reviews.

Other ways of identifying an incident

medical record reviews and clinical audit
peer review
morbidity and mortality meetings
complaints, satisfaction surveys and other methods for collecting feedback from the patient and/or carer/family
reviewing coroners' reports.

Other surveillance methods include the use of trigger tools or Limited Adverse Occurrence Screening (LAOS).

The ability to identify incidents ...

...is the first step in improving patient care. If you think an incident is serious, talk to your local manager immediately. If it is after hours, talk to the most senior manager available. IIMS is not a substitute for verbal communication.

If you are a manager...

... it is your responsibility to foster a culture of safety that enables staff to identify, notify and be involved in the investigation of incidents.

Consider Facilitated Incident Monitoring

This is about creating an environment where incidents are easily recognised. Allocating time for this in the weekly department/ward meeting provides the ideal setting for the opportunistic identification of incidents. Further information about Facilitated Incident Monitoring can be found in The Clinician's Toolkit for Improving Patient Care.

For more on identification, refer to Brand C, Elkadi S, Tropea J 2005, Measurement for Improvement Toolkit, Clinical Epidemiology & Health Service Unit, Royal Melbourne Hospital, Melbourne Health.

For more on trigger tools, refer to For more on trigger tools, see Rozich, J D, Haraden C R and Resar R K, 2003, Adverse drug event trigger tool: a practical harm methodology for measuring medication related harm, Quality and Safety in Health Care; 12; 194-200. This is a CIAP jumpstart link. Use your CIAP login.