Clinical Risk Management

  • What is Risk Management?

    Other risk management information:

    In order to achieve the goal of a safe environment at The Royal Children's Hospital (RCH) for all patients, staff and visitors, appropriate risk management must be undertaken.  Risk management is defined as "the culture, processes and structures that are directed towards realizing potential opportunities whilst managing adverse effects" AS/NZ 4360.

    The risk management process comprises a series of steps.  These steps are depicted below.






    View the RCH Risk policy. (intranet only)

    What are my risk management responsibilities?

    All staff have a responsibility to be actively involved in risk management.  The extent to which staff are involved is dependant upon the role they play at the RCH.  General staff are responsible for:

    • Reporting incidents via the Victorian Health Incident Management System (VHIMS)
    • Identifying and assessing risks in accordance with the RCH's risk management procedure;
    • Providing additional information about a risk when requested; and
    • Embedding risk management in day-to-day operations within their areas

    The key risk management responsibilities of line managers are:

    • Participating in the review and update of the RCH's operational risk profiles;
    • Ensuring that risks are identified, managed and monitored on an ongoing basis within their areas, in accordance with the process set out in this document. This includes ensuring the effectiveness of key controls;
    • Overseeing the coherent and consistent use of risk management techniques, (in particular, risk assessment and mitigation techniques) by those personnel reporting to them;
    • Embedding risk management in operational decision making and in day-to-day operations within their areas;
    • Having risk management as a regular agenda item for team meetings; and
    • Ensuring that risks are accurately and timely recorded in order to facilitate risk management reporting.

    What is an incident?

    An incident is an event which could have or did lead to unintended or unnecessary harm to a person and/or a complaint, loss or damage. Incidents include near misses, adverse events, sentinel events and unsafe acts.

    How do I report an incident?

    At the RCH an electronic incident reporting system called VHIMS is used to capture incident data.

    The incident or hazard should be entered into the incident reporting system as soon as practical, to ensure accurate recording of detail.  The staff member reporting the incident or hazard should also inform their manager of the incident. 

    The Incident Reporting and Management procedure outlines the purpose of the clinical incident reporting system.

    To learn more about VHIMS please complete the Department of Health VHIMS Education package.

    What happens then?

    The incident report will be forwarded via the system to your nominated manager.  If there are risk control activities that can be conducted at a local level then these should be commenced and the matter should be discussed at your team meeting.  Incidents or hazards that have a major or catastrophic potential or actual outcome will be formally investigated.

    What should the incident reporting system be used for?

    The incident reporting system should be used to report incidents that caused or had the potential to cause harm to patients, staff and visitors (including contractors).  It is not intended to capture complications of disease processes.

    Examples of appropriate use would be:

    • The wrong dosage of a medication administered to a patient
    • A dosage of medication not given when prescribed to be given
    • The wrong treatment given to a patient e.g. wrong procedure conducted
    • A staff member injured in the course of their duties e.g. back injury while lifting
    • Injury to a visitor e.g. fall on a wet floor in the hallway

    Examples of inappropriate use would be:

    • To performance manage a staff member
    • To allocate blame for an event 
    • For personal grievances
    • For HR related matters eg harassment or discrimination

    Mortality and Morbidity Review Meetings

    Mortality and Morbidity review meetings are a requirement of all medical departments within The Royal Children's Hospital.


    Selected cases are presented at mortality and morbidity review (M&M) meetings for the purpose of:

    • discussing management decisions
    • providing a learning opportunity focussed on system thinking
    • identifying opportunities to improve patient safety and quality of care.

    Mortality review

    • There is an organisational expectation that all inhospital deaths will be reviewed using the Departmental Mortality & Morbidity Review form.
    • Issues should be identified and, where appropriate, recommendations for system change made. It is important that the person responsible for implementing the change is identified and a due date established.
    • Progress with implementation of recommendations should be reviewed at subsequent meetings.
    • A department may consider that an independent review would be beneficial.

     Morbidity review

    • Cases should be summarised and reviewed using the Departmental Mortality & Morbidity Review form.
    • Issues should be identified and, where appropriate, recommendations for system change made. It is important that the person responsible for implementing the change is identified and a due date established.
    • Progress with implementation of recommendations should be reviewed at subsequent meetings.

    Documentation and reporting

    Departments should record cases reviewed using the Departmental Mortality & Morbidity Review form.

    Upon completion, please send forms through to the Quality unit at

    What is a Sentinel Event?

    A sentinel event is a subset of adverse events specified by the Department of Health (DH).  These events rarely occur but are more serious and are therefore reported to DH and investigated immediately using a Root Cause Analysis process

    DH describes a sentinel event as a relatively infrequent, clear-cut event that occurs independently of a patient's condition.  They commonly reflect hospital systems and process deficiencies and result in unnecessary outcomes for patients.

    DH has specifically outlined nine sentinel events, which must be reported:

    1. Procedures involving the wrong patient or body part
    2. Intravascular gas embolism resulting in serious neurological damage or mortality
    3. Haemolytic blood transfusion resulting from ABO incompatibility
    4. Patient suicide in hospital *
    5. Retained instrument or other material after surgery, requiring re-operation or further surgical procedure
    6. Medical error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
    7. Maternal death or serious disability associated with labour or delivery
    8. Infant discharged to wrong family
    9. Other

    *Episodes of suicide that are reportable under the Mental Health Act (1986) should continue to be reported to the Chief Psychiatrist.

    More information can be found at the DH Clinical Risk Management Website.

    How do I report a Sentinel Event?

    If a sentinel event occurs;

    • Ensure the patient is cared for appropriately
    • Notify your department head / nurse unit manager (NUM) / manager
    • Once the safety of the patient is ensured, complete an incident report

    The Quality Unit will notify DH and follow appropriate procedures. A root cause analysis will be conducted. Please refer to Critical Incident Review Procedure.

    What is a "Root Cause Analysis"?

    A Root Cause Analysis (RCA) is a method of investigation.  The purpose is to identify organisational deficiencies that may not be immediately apparent and which may have contributed to the cause of the event.  A RCA report also includes risk reduction strategies to reduce the chance of a similar event occurring again.

    What do I tell the patient and family?

    Open disclosure is the open discussion of incidents that result in harm to a patient while receiving health care. For information to guide this process see the Open Disclosure site.