In this section
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)
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:
The key risk management responsibilities of line managers are:
An event or circumstance that could have resulted, or did result, in unintended or unnecessary harm to a person receiving care (Australian Commission on Safety and Quality in Healthcare, ACSQHC, 2006). Incidents include adverse events, near misses, sentinel events and hazards.
A clinical incident can be an adverse event: An incident in which harm resulted to a person receiving health care (ACSQHC, 2006).
A clinical incident can be a near miss: An incident that did not cause harm (ACSQHC, 2006). Near miss encompasses incident that had potential to cause harm but didn't, due to timely intervention and/or luck/chance.
Sentinel events are relatively infrequent, clear-cut events that occur independently of a patient's condition, commonly reflect hospital system and process deficiencies and result in unnecessary outcomes for patients. Please refer to the information below for management of a sentinel event.
The Victorian Health Incident Management System (VHIMS) is used to capture incident data at the RCH. This could include clinical, OH&S and non-clinical incidents.
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.
A score of 1, 2, 3, or 4 is given to each incident. This measures the severity of the impact caused to either a person or organisation following an incident.
The ISR is assigned by an algorithm set into VHIMS based on answers to a set of questions related to:
No Harm/Near Miss
The ISR will be shown in the severity section of VHIMS.
The incident report will be forwarded via the system to your nominated manager (Head of Department/Nurse Unit Manager). It is their responsibility to ensure the following actions are carried out in VHIMS:
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 by Strategy and Improvement.
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:
Examples of inappropriate use would be:
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:
*Episodes of suicide that are reportable under the Mental Health Act (1986) should continue to be reported to the Chief Psychiatrist.
If you are unsure whether your incident is a sentinel event please contact your Quality Manager or consult the DH Clinical Risk Management Website for more information.
If a sentinel event occurs;
The Quality Unit will notify DH and follow appropriate procedures. A root cause analysis will be conducted. Please refer to Critical Incident Review Procedure.
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.
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.
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:
Departments should record cases reviewed using the Departmental Mortality & Morbidity Review form.
Upon completion, please send forms through to the Quality unit at firstname.lastname@example.org.