These videos have been developed to help staff in the WA health system understand key principles and processes for the management of clinical incidents. They have been produced by Dr Matthew Thomas in collaboration with the Department of Health’s Patient Safety Surveillance Unit and the WA Country Health Service.
Dr Thomas is one of Australia’s leading scientists in the field of Human Factors and safety management in high risk work environments. He provides expert advice and Human Factors solutions to airlines, the road and rail industry, healthcare, mining, utilities, construction and defence.
Purpose of clinical incident management
In our complex system, sometimes things do not go entirely as anticipated, and on rare occasions this can result in patient harm. Clinical incident management is critical to minimising harm, understanding why an incident might have occurred, and putting in place strategies to make our system safer.
The clinical incident management process
The clinical incident investigation process consists of initial identification of the incident, notification into the Clinical Incident Management System Datix CIMS, analysis and investigation of the incident, reporting of the outcomes from the investigation, formulation of actions/recommendations to prevent similar incidents from occurring, and implementing and evaluating the effectiveness of these actions.
The systems approach to investigation
Clinical incidents arise from gaps, vulnerabilities or flaws in the way in which we deliver care, be it our resourcing, our equipment, our policies, guidelines, training, or simply the performance variability that comes naturally from being human. The systems approach to incident investigation searches for these gaps and deficiencies in how we do business, and attempts to build stronger, more resilient, reliable systems of healthcare delivery.
Error tolerance
A truly safe system is one that expects and anticipates the errors that come naturally to us as humans. In healthcare we need to understand why errors are made and the error-producing conditions in our systems of work that give rise to errors. This is often done via risk management activities.
Human factors
Problems often arise because we have a mismatch between our expectations of human performance and technology. Human factors takes into consideration the interaction of all the components of the 'system' of work, including people, processes, environment, equipment, and the broader organisational and cultural context.
The London Protocol
The London Protocol was refined in 2004 and is a systems based methodology to investigate clinical incidents. The protocol has a framework which identifies ‘care delivery problems’ and the contributory factors which influence practice and outcomes. The key questions of 'What happened?'; 'How did it happen?' and 'Why did it happen?' frame this methodology.
Improving the strength of recommendations
Effective and sustainable recommendations that come out of a clinical incident investigation make the most important contribution to improving patient safety by changing the way in which we deliver care. Short-term localised actions, such as re-training staff, don’t target the underlying causes of clinical incidents, and leave behind unchanged the vulnerabilities in our systems of care.
Closing the loop
Making sure our recommendations from a clinical incident investigation have been implemented and have resulted in the quality improvements we had hoped is the final stage of the clinical incident investigation process. We call this 'closing the loop'.
Open disclosure
When there are avoidable deficiencies in the care that we deliver, open disclosure is our opportunity to apologise to our patients and their families for the harm we have caused, and be transparent in our efforts to understand the reasons why and put in place strategies to avoid similar harm in the future.
Consumer’s perspective in incident investigation
As part of a truly patient-centred health service delivery, it is important to involve consumers’ perspectives in the clinical incident investigation process.
Involving patients and family in incident investigation
The patients’ perspectives can reveal much about the way in which we have designed our processes for the delivery of care, and can reveal many aspects that we either take for granted or accept as normal.
Links to risk management
Clinical incident investigation can run the risk of making local changes to specific processes but not achieving system-wide change, and of focussing on the clinical features of an incident, and not seeing the trends in common underlying systems deficiencies. To address this issue we need to ensure that lessons are learned across sites, facilities and our regions and ongoing risks identified are managed.
Just culture
Through the clinical incident management process, those involved in an incident sometimes fear the potential implications an incident might have on their career, their training, their contract and future employment opportunities. Adopting a Just Culture approach challenges punitive approaches historically taken in old models of safety and decouples the incident investigation and performance management processes.
The second victim
The 'second victim' is a term we use in healthcare, and across other industries, to describe that fact that it is not only patients or consumers that are harmed by adverse events. Those staff who are involved in a clinical incident are also victims and we need to understand, respect and support them as we do our patients.
Performance management and incident investigation
Old models of safety see the cause of clinical incidents sitting squarely on the shoulders of those immediately responsible for the delivery of care. This has lead to issues surrounding performance management and issues surrounding patient safety becoming intertwined in the clinical incident investigation process. The systems approach to safety urges us to unpick this relationship, and separate out performance management from the clinical incident investigation process.
Safety II safety differently
Traditional models of safety have focused on identifying the 'problems' in our systems of work and trying to eliminate these problems as factor that cause incidents. Safety II is an approach that accepts that there will always be problems, gaps, deficiencies, and complexities in the systems we create, and places the emphasis not only on eliminating problems, but also on supporting and promoting the active behaviours of individuals and teams that are in play everyday to manage the shortcomings in our systems of work.
More information
Patient Safety and Surveillance Unit
Email: pssu@health.wa.gov.au
Last reviewed: 08-04-2022
Produced by
Patient Safety Surveillance Unit