Clinical incidents in Australia

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Any medical incident that causes serious harm or death will be reported as Australian Sentinel Events (SEs or ASE) which is an Australian national serious medical error or incident reporting system. It includes a set of preventable adverse events that result in serious harm or death to a patient. These events are clearly defined and recognized as being preventable if the proper safeguards are in place. [1] [2]

Contents

A clinical incident is defined as any event that resulted or could have resulted in minor to serious harm or death to a patient. [3]

History

In 1992, an estimated of 18,000 deaths were associated with adverse events (AE) in Australia. [4]

In 2002, all states and territories have agreed to contribute to a set of 8 categories of the National Sentinel Events (NSEs). Later, a revised Australian Sentinel Events (ASE) list which includes 10 categories was endorsed by Australian Health Ministers in December 2018 . [1]

Regulation

The report of serious clinical incidents including SE are mandatory for all public hospitals and all private licensed health care facilities across Australia.

The ASE or SEs include 10 categories, however different states and territories may have additional categories on the Sentinel Events. [5]

While each state and territory have their own health department to oversee and investigate all clinical incidents, the Australian Commission on Safety and Quality in Health Care is responsible for managing all the incident happened in Australian hospitals, clinics and other communities healthcare facilities in order to improve patient safety. [6]

Type of incident

Ecah state and territory have their own different type of incident reporting rating system.

New South Wales

Harm Score 1 as the most severe harm including sentinel events, to Harm Score 4 as minor harm or no harm.

Western Australia

In Western Australia, Severity Assessment Codes are used in WA health systems to determine the level of a clinical incidents. Rating from SAC 1 including sentinel event as the severe harm, to SAC 3 as minor or no harm. [7]

Sentinel events

All states and territories have agreed the 10 categories of sentinel event which include:

Type of event [8]
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 in an acute psychiatric unit or acute psychiatric ward
Medication error resulting in serious harm or death
Use of physical or mechanical restraint resulting in serious harm or death
Discharge of an infant or child to an unauthorised person
Use of an incorrectly positioned oro- or naso- gastric tube resulting in serious harm or death

While some state and territory may have additional category, such as in Victoria has added category 11 of “All other adverse patient safety events resulting in serious harm or death.”

Prevalence

Australian enjoy high-quality healthcare services and one of the best healthcare systems in the world with most incidents recorded are of minor or no harm, a very low rate of medical incidents causing significant harm to patients.

There were 54 sentinel events recorded in 2021-2022 across all Australian states and territories [1]

New South Wales

In 2021, New South Wales has 83,355 incidents in which 96.5% are Harm Score 3 and 4 which are minor or no harm. 0.3% are of Harm Score 1 which include about 20 sentinel events. [9] [10]

Most of the incidents are falls, concerning behavior and skin integrity such as pressure injuries which result in minor or no harm. About 272 cases which include sentinel events are of significant harm. [1]

Sentinel event2019–20202020–20212021–2022
Total Events91912

Victoria

In 2019-2020, Victoria has recorded 23 of the 10 categories of SE and an additional category has 163 SEs. [5]

Sentinel events2019-2020
10 categories of sentinel event23
Additional category163
Total SEs186

Queensland

The table below is the sentinel events in Queensland.

sentinel eventIncidents
2015/16 [11] 15
2016/17 [11] 2

Western Australia

In 2022/23, Western Australia has recorded 35,957 incidents with 91.7% being minor or no harm, and 3.2% of moderate injury. While serious harm and death accounted for about 1% and about 3% are missing outcome/no data. [12]

The most common causes of incidents are due to fall and unpredictable behavior.

In Western Australia, the sentinel events will be reported as SAC1 which includes the 10 categories of National Sentinel Events and Other SAC1 clinical incidents. [13]

SAC1 [12] 2020/212021/222022/23
Sentinel Events202730
Other SCA1 clinical incidents532526555

South Australia

In 2022–2023, South Australia has 78,806 incidents in which majority are minor harm or no harm. There were about 0.25-0.55 percent (about 200 cases) are of serious harm in which falls incidents and sentinel events have accounted for 157 and 5 cases respectively. [13]

Most incidents are falls, medication and challenging behavior, fortunately most of which 99% are near miss or no harm including medication. [14]

There are total of 5 sentinel event in 2021-2022 which is the same as in 2022–2023. [14]

Northern Territory

The incidents number of sentinel events which also include the 10 categories since 2019 and 8 core categories before 2019 in Northern Territory. [15]

sentinel eventIncidents
2020/212

Contributing factors

In terms of healthcare providers, violations to procedures or guidelines, rule-based mistakes, communication errors and documentation errors are some of the most common contributing factors causing clinical incidents in Australia. [16]

In terms of concerning patients, cognitive factors, communication and challenging behaviour are some of the common contributing factors. Most commonly caused fall incidents which usually result in minor or no harm, yet about 1% resulted in serious harm or even death. [16] [14]

Efforts to improve patient safety

Department of Health of each state and territory; and Australian Commission on Safety and Quality in Health Care collects data of the incidents happened each year. This data collection can helps identify and recognize areas for improvement which aims to prevent similar incidents from happening again.

For example, New South Wales government has developed plans to prevent pressure injury such as keeping the head of the bed as flat as possible and if needed to elevate the bed, it must be at no more than 30-degrees. [17]

As fall incidents often occur in healthcare facilities, government has therefore applied a knee break function preventing patient from sliding down the bed which aims to reduce fall incidents.

An other example is that in Western Australia once incident is identified, healthcare providers must take immediate action such as removing malfunction medical equipment, removing harmful substances from the environment. [7]

Related Research Articles

Transfusion medicine is the branch of medicine that encompasses all aspects of the transfusion of blood and blood components including aspects related to hemovigilance. It includes issues of blood donation, immunohematology and other laboratory testing for transfusion-transmitted diseases, management and monitoring of clinical transfusion practices, patient blood management, therapeutic apheresis, stem cell collections, cellular therapy, and coagulation. Laboratory management and understanding of state and federal regulations related to blood products are also a large part of the field.

A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care provider.

A medical error is a preventable adverse effect of care ("iatrogenesis"), whether or not it is evident or harmful to the patient. This might include an inaccurate or incomplete diagnosis or treatment of a disease, injury, syndrome, behavior, infection, or other ailments.

<span class="mw-page-title-main">Electronic health record</span> Digital collection of patient and population electronically stored health information

An electronic health record (EHR) is the systematized collection of patient and population electronically stored health information in a digital format. These records can be shared across different health care settings. Records are shared through network-connected, enterprise-wide information systems or other information networks and exchanges. EHRs may include a range of data, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal statistics like age and weight, and billing information.

Pharmacovigilance, also known as drug safety, is the pharmaceutical science relating to the "collection, detection, assessment, monitoring, and prevention" of adverse effects with pharmaceutical products. The etymological roots for the word "pharmacovigilance" are: pharmakon and vigilare. As such, pharmacovigilance heavily focuses on adverse drug reactions (ADR), which are defined as any response to a drug which is noxious and unintended, including lack of efficacy. Medication errors such as overdose, and misuse and abuse of a drug as well as drug exposure during pregnancy and breastfeeding, are also of interest, even without an adverse event, because they may result in an adverse drug reaction.

<span class="mw-page-title-main">Adverse drug reaction</span> Harmful, unintended result of medication

An adverse drug reaction (ADR) is a harmful, unintended result caused by taking medication. ADRs may occur following a single dose or prolonged administration of a drug or may result from the combination of two or more drugs. The meaning of this term differs from the term "side effect" because side effects can be beneficial as well as detrimental. The study of ADRs is the concern of the field known as pharmacovigilance. An adverse event (AE) refers to any unexpected and inappropriate occurrence at the time a drug is used, whether or not the event is associated with the administration of the drug. An ADR is a special type of AE in which a causative relationship can be shown. ADRs are only one type of medication-related harm. Another type of medication-related harm type includes not taking prescribed medications, known as non-adherence. Non-adherence to medications can lead to death and other negative outcomes. Adverse drug reactions require the use of a medication.

An adverse effect is an undesired harmful effect resulting from a medication or other intervention, such as surgery. An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. The term complication is similar to adverse effect, but the latter is typically used in pharmacological contexts, or when the negative effect is expected or common. If the negative effect results from an unsuitable or incorrect dosage or procedure, this is called a medical error and not an adverse effect. Adverse effects are sometimes referred to as "iatrogenic" because they are generated by a physician/treatment. Some adverse effects occur only when starting, increasing or discontinuing a treatment. Using a drug or other medical intervention which is contraindicated may increase the risk of adverse effects. Adverse effects may cause complications of a disease or procedure and negatively affect its prognosis. They may also lead to non-compliance with a treatment regimen. Adverse effects of medical treatment resulted in 142,000 deaths in 2013 up from 94,000 deaths in 1990 globally.

Computerized physician order entry (CPOE), sometimes referred to as computerized provider order entry or computerized provider order management (CPOM), is a process of electronic entry of medical practitioner instructions for the treatment of patients under his or her care.

In pharmaceuticals, an adverse event (AE) is any untoward medical occurrence in a patient or clinical investigation subject administered a pharmaceutical product and which does not necessarily have a causal relationship with this treatment. An adverse event can therefore be any unfavourable and unintended symptom or sign or disease temporally associated with the use of a medicinal (investigational) product, whether or not related to the medicinal (investigational) product.

Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The magnitude of avoidable adverse events, often known as patient safety incidents, experienced by patients was not well known until the 1990s, when multiple countries reported significant numbers of patients harmed and killed by medical errors. Recognizing that healthcare errors impact 1 in every 10 patients around the world, the World Health Organization (WHO) calls patient safety an endemic concern. Indeed, patient safety has emerged as a distinct healthcare discipline supported by an immature yet developing scientific framework. There is a significant transdisciplinary body of theoretical and research literature that informs the science of patient safety with mobile health apps being a growing area of research.

A patient safety organization (PSO) is a group, institution, or association that improves medical care by reducing medical errors. Common functions of patient safety organizations are data collection, analysis, reporting, education, funding, and advocacy. A PSO differs from a Federally designed Patient Safety Organization (PSO), which provides health care providers in the U.S. privilege and confidentiality protections for efforts to improve patient safety and the quality of patient care delivery

A never event is the "kind of mistake that should never happen" in the field of medical treatment. According to the Leapfrog Group never events are defined as "adverse events that are serious, largely preventable, and of concern to both the public and health care providers for the purpose of public accountability."

Health information technology (HIT) is health technology, particularly information technology, applied to health and health care. It supports health information management across computerized systems and the secure exchange of health information between consumers, providers, payers, and quality monitors. Based on a 2008 report on a small series of studies conducted at four sites that provide ambulatory care – three U.S. medical centers and one in the Netherlands, the use of electronic health records (EHRs) was viewed as the most promising tool for improving the overall quality, safety and efficiency of the health delivery system.

The German Coalition for Patient Safety (APS) – in German "Aktionsbündnis Patientensicherheit (APS)", was established in 2005 and located in Bonn is a German non-profit association of organisations and individuals interested and involved in promotion of patient safety.

Barcode technology in healthcare is the use of optical machine-readable representation of data in a hospital or healthcare setting.

Clinical point of care (POC) is the point in time when clinicians deliver healthcare products and services to patients at the time of care.

<span class="mw-page-title-main">David W. Bates</span> Researcher

David Bates is an American physician, biomedical informatician, and professor, known for his work regarding the use of health information technology (HIT) to improve the safety and quality of healthcare, in particular by using clinical decision support. Bates has done work in the area of medication safety. He began by describing the epidemiology of harm caused by medications, first in hospitalized patients and then in other settings such as the home and nursing homes.

The Pennsylvania Patient Safety Authority is an independent state agency located in Harrisburg, Pennsylvania, United States. Its mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients. The Authority was established under Act 13 of 2002, the Medical Care Availability and Reduction of Error (MCARE) Act. The Authority began collecting Serious Events and Incidents in June 2004, making Pennsylvania the only state in the United States to require reporting of both of the aforementioned event types. Acute healthcare facilities that report events through the Authority include hospitals, ambulatory surgical facilities, birthing centers, and abortion facilities. In June 2009, the Authority began collecting infection reports from nursing homes.

A significant event audit (SEA), also known as significant event analysis, is a method of formally assessing significant events, particularly in primary care in the UK, with a view to improving patient care and services. To be effective, the SEA frequently seeks contributions from all members of the healthcare team and involves a subsequent discussion to answer why the occurrence happened and what lessons can be learned. Events triggering a SEA can be diverse, include both adverse and critical events, as well as good practice. It is most frequently required for appraisal, revalidation and continuing professional development.

<span class="mw-page-title-main">Drug labelling</span>

Drug labelling is also referred to as prescription labelling, is a written, printed or graphic matter upon any drugs or any of its container, or accompanying such a drug. Drug labels seek to identify drug contents and to state specific instructions or warnings for administration, storage and disposal. Since 1800s, legislation has been advocated to stipulate the formats of drug labelling due to the demand for an equitable trading platform, the need of identification of toxins and the awareness of public health. Variations in healthcare system, drug incidents and commercial utilization may attribute to different regional or national drug label requirements. Despite the advancement in drug labelling, medication errors are partly associated with undesirable drug label formatting.

References

  1. 1 2 3 4 NSW Government (n.d.). "Sentinel events". Sentinel events reporting.
  2. ↑ IHPA. "Pricing and funding for safety and quality: Sentinel events" (PDF).
  3. ↑ "Clinical incidents". www.digitalhealth.gov.au. Retrieved 2024-08-31.
  4. ↑ KABLE, A. K.; GIBBERD, R. W.; SPIGELMAN, A. D. (2002-08-01). "Adverse events in surgical patients in Australia". International Journal for Quality in Health Care. 14 (4): 269–276. doi:10.1093/intqhc/14.4.269. ISSN   1353-4505. PMID   12201185.
  5. 1 2 "Supporting patient safety: learning from sentinel events" (PDF).
  6. ↑ Independent Hospital Pricing Authority. "Pricing and funding for safety and quality: Sentinel events" (PDF).
  7. 1 2 Government of Western Australia. "Clinical incident management guidelines 2019" (PDF).
  8. ↑ "Sentinel events NBEDS 2019-". Australian Institute of Health and Welfare. Retrieved 1 September 2024. Creative Commons by small.svg  This article incorporates textfrom this source, which is available under the CC BY 4.0 license.
  9. ↑ "Patient-related incident data - Clinical Excellence Commission". www.cec.health.nsw.gov.au. Retrieved 2024-08-31.
  10. ↑ "Patient-related incident data - Clinical Excellence Commission". www.cec.health.nsw.gov.au. Retrieved 2024-09-01.
  11. 1 2 Caldwell, Felicity (2018-01-30). "Sorry, wrong patient: Major Queensland hospital errors revealed". Brisbane Times. Retrieved 2024-08-31.
  12. 1 2 Department of Health, Government of Western Australia. "Your safety in our hands hospital" (PDF).
  13. 1 2 "WA Health System SAC" (PDF).
  14. 1 2 3 Government of South Australia. (2023). Patient Safety Report 2023.https://www.sahealth.sa.gov.au/wps/wcm/connect/1b029a77-8634-49a5-991d-f87612d583c6/Final+Patient+Safety+Report+2023.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-1b029a77-8634-49a5-991d-f87612d583c6-oHu9fVm
  15. ↑ "Royal Darwin Hospital patient died due to 'medication error', remote NT patient seriously harmed, data shows - ABC News". amp.abc.net.au. Retrieved 2024-08-31.
  16. 1 2 Adie, Khaled; Fois, Romano A.; McLachlan, Andrew J.; Walpola, Ramesh L.; Chen, Timothy F. (2021). "The nature, severity and causes of medication incidents from an Australian community pharmacy incident reporting system: The QUMwatch study". British Journal of Clinical Pharmacology. 87 (12): 4809–4822. doi:10.1111/bcp.14924. ISSN   0306-5251. PMID   34022060.
  17. ↑ New South Wales government. "Pressure injury prevention and management" (PDF).
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