A system that embraces a learning culture aimed at preventing harmful events from re-occurring and identifying risks before they eventuate is a system focused on patient safety. Policies and procedures that aim to share lessons learned and follow a no-blame approach are indicative of a learning culture. The WA health system employs a number of approaches to close the loop on patient safety events.
Notifier access to notified incidents
Health staff who have notified a clinical incident in Datix CIMS have read-only access to both the notification and the investigation screens for that incident. This enables notifiers to receive feedback about what has been investigated and implemented as a result of their notification and aligns with the core principles of transparency, accountability, probity and fairness outlined in the CIM Policy.
Staff may only access information for the purpose of closing the loop on their initial notification and are responsible for maintaining the confidentiality and security of clinical incident notification and investigation information in the Datix CIMS. The goal of clinical incident investigation is to identify health care system factors that could have contributed to patient harm. Clinical incidents are investigated and reported in Datix CIMS using a no blame approach.
Evaluation of recommendations
The development, implementation, and evaluation of effectiveness of recommendations is an integral part of ensuring that lessons are learnt from clinical incidents so that improvements in health care delivery and patient care are achieved. Under the Clinical Incident Management Policy recommendations must address the contributing factors of a clinical incident. The key requirements outlined in the Policy are:
- all SAC 1 recommendations must be both implemented and evaluated within six months (182 calendar days) of the investigation report submission
- an evaluation of SAC 1 recommendations must also be forwarded to PSSU within those six months (182 calendar days) of the investigation report submission
- all SAC 2 and 3 recommendations must be implemented and evaluated within 6 months (182 calendar days) of the investigation being completed. Monitoring of these processes must occur at the local level.
The CIM Guideline and Toolkit contain information about recommendation development, implementation and evaluation. This includes guidance on how to develop strong, system-based recommendations which are more sustainable and effective than person-based recommendations.
See these videos on improving the strength of recommendations (external site) and closing the loop (external site) presented by Dr Matthew Thomas.
In 2016 the PSSU launched the Closing-the-Loop Program to progress the safety and quality culture within the WA health system. The program focused on assisting sites understand and meet CIM Policy requirements for SAC 1 clinical incident investigation and evaluation requirements, including how to develop strong, sustainable recommendations and what methods could be used to evaluate whether those recommendations were working to reduce preventable harm. Resources relating to the Closing-the-Loop Program are retained here, noting that there are references to earlier versions of the CIM Policy.
Action plan
Presentation
Poster
Tools
A learning organisation and quality improvement
A commitment to ongoing learning and quality improvement is a critical factor in delivering a high standard of health care. To facilitate the development of this learning culture all health staff need an awareness of quality improvement principles which focus on system theory and human factors.
The Clinical Incident Management Policy requires sites to share de-identified information on learnings from clinical incidents, including actions taken in response to clinical incidents to prevent similar events from reoccurring. The Clinical Incident Management Guideline and Toolkit detail how this may be achieved.
Clinical risk management is important as a process in conjunction with CIM as it proactively seeks to reduce identified clinical risks to an acceptable level. If harm has occurred, risk management processes review what can be implemented to reduce it from re-occurring and then ascertain if the residual clinical risk is acceptable. If it is not, this is the part of the cycle which aims to look at other quality improvement strategies which can be implemented to improve the quality of clinical care as part of a continuous improvement cycle. Watch this video which explains the link between clinical incident management and risk management (external site).
More information
Patient Safety and Surveillance Unit
Email: pssu@health.wa.gov.au
Last reviewed: 08-04-2022
Produced by
Patient Safety Surveillance Unit