Incident investigations in NSW public hospitals are required when there are poor outcomes and adverse clinical incidents. The reporting and investigation of poor outcomes and adverse clinical incidents are important to maintaining and improving the quality of the provision of health in the public system. The intention is that hospital staff learn how to avoid similar mistakes happening in the future and that there is process and procedural improvement.
Incident reporting and investigation
The clinical incident reporting system in NSW public health system is called the Incident Information Management System (‘IIMS’). Staff at NSW public hospitals are required to report all clinical incidents in the IIMS. The objective of the IIMS system is identify significant issues, risks and trends relating to clinical care and share the lessons learned to improve the safety of patients and the quality of care.
Incidents reported in the IIMS are ranked according to a Severity Assessment Code (‘SAC’). Rankings range from a SAC1 (extreme risk) to SAC4 (low risk). All SAC1 and selected SAC2 – 4 incidents are subject to a Root Cause Analysis (‘RCA’) investigation.
RCA investigations aim to identify the root cause or causes of an incident. During the investigation, consideration is also given to the circumstances surrounding the incident including the chain of events leading up to the incident and any contributing factors (this aspect is known as the London Protocol).
The investigation itself involves a team of independent clinicians being appointed to review the clinical records, interview the staff members involved and recommend changes to policies and procedures to try and reduce the risk of a similar incident happening again. Investigators are also encouraged to involve the patient or their family in the investigation including by interviewing them and extending an apology, if appropriate. However, it is important to note than an apology is not in itself an admission of liability under NSW legislation – it can, however, be an acknowledgement of the pain and suffering caused to the patient or their family as the result of the avoidable incident.
All SAC2 – 4 incidents are also reviewed by management at the hospital where the incident occurred.
Can investigation reports be used as evidence in medical negligence proceedings?
RCA reports are not admissible as evidence of fault or wrongdoing in medical negligence proceedings. This is to ensure open and honest disclosure by hospital staff and investigators without fear of legal ramifications (although the RCA team is required to report to the CEO of the local health district if they believe there was professional misconduct, unsatisfactory professional conduct or impairment of a particular clinician).
Even though RCA reports cannot be relied upon in medical negligence proceedings, they can still be very useful for lawyers in identifying and understanding the key issues in the patient’s care. This in turn can help the lawyer to select an appropriately qualified expert to provide an opinion in the case.
If you or someone you know has had a poor outcome as a result of receiving substandard treatment at a public hospital, our team of expert medical negligence lawyers would be pleased to meet with you to discuss your options and entitlements. Please call us on (02) 4050 0330 or make an online online booking for a free initial consultation.