What is a ‘reportable incident’ for the purposes of a Root Cause Analysis under The Health Administration Act 1982
It is fundamentally important for the proper delivery of public health services that serious clinical incidents are identified, investigated and processes implemented for improvement and prevention.
Section 20M of the Health Administration Act 1982 requires that an independent team be appointed to carry out a thorough investigation (root cause analysis) into reportable incidents reported to the Chief Executive Officer of a hospital with a view to:
- Determining the cause of the incident;
- Investigating whether the incident involved professional misconduct or unsatisfactory professional conduct by a person who is a visiting practitioner or staff member or may indicate that such a person is suffering from an impairment;
- Determining whether the incident was the result of a serious systemic problem in the organisation; and
- Making any recommendations as to the need for changes or improvements in relation to a procedure or practice arising out of the incident.
Under the PD2020_047 Incident Management Policy in place from December 2020 the definition of reportable incident includes:
- The death of a patient unrelated to the natural course of the illness and differing from the immediate expected outcome of the patient management;
- Suspected suicide of a person (including an inpatient or community patient) who has received care or treatment for a mental illness from the relevant Health Services organisation where the death occurs within 7 days of the person’s last contact with the organisation or where there are reasonable clinical grounds to suspect a connection between the death and the care or treatment provided by the organisation;
- Suspected homicide committed by a person who has received care or treatment for mental illness from the relevant Health Services organisation within six months of the person’s last contact with the organisation or where there are reasonable clinical grounds to suspect a connection between the death and the care or treatment provided by the organisation; · Unexpected intra-partum stillbirth;
Or
- An Australian Sentinel Event (ASE) (see below for definitions of expressions used to describe ASEs) being:
- Surgery or other invasive procedure performed on the wrong site resulting in serious harm or death.
- Surgery or other invasive procedure performed on the wrong patient resulting in serious harm or death.
- Wrong surgical or other invasive procedure performed on a patient resulting in serious harm or death.
- Unintended retention of a foreign object in a patient after surgery or other invasive procedure resulting in serious harm or death.
- Haemolytic blood transfusion reaction resulting from ABO incompatibility resulting in serious harm or death.
- Suspected suicide of a patient within an acute psychiatric unit or acute psychiatric ward.
- Medication error resulting in serious harm or death. Incident Management APPENDICES PD2020_047 Issue date: December-2020 Page 58 of 65 NSW HEALTH PROCEDURE
- Use of physical or mechanical restraint resulting in serious harm or death.
- Discharge or release of a child to an unauthorised person.
- Use of an incorrectly positioned oro- or naso-gastric tube resulting in serious harm or death.
If you or a loved one have been adversely impacted by a serious clinical incident, there are avenues for redress. Our team of expert personal injury lawyers would be pleased to meet with you to discuss your options. You can either book an appointment online or call us on (02) 4050 0330 for an obligation-free consultation.
