Clinical incident management

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

SAC2 incidents have a patient outcome of moderate harm.

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

Sentinel events: a subset of SAC1 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 in our hospitals, demonstrating our strong and proactive approach to patient safety.

We have reported the number of clinical incidents which occurred in public hospitals by their severity for each financial year. To provide context, we have also shown the same data as rates per patient day.