learning from clinical incidents: a snapshot of patient...

Learning from Clinical Incidents: A Snapshot of Patient Safety in

Western Australia

2010-2011

Acknowledgements

The Patient Safety Directorate (PSD) would like to thank and acknowledge the contribution

of all clinical staff who have devoted their time and effort to collecting and reporting clinical

incidents. We would also like to acknowledge the patients and their families who have

experienced unintended harm whilst receiving care in our health system. By reporting,

investigating, implementing change and sharing the lessons learned, we aim to reduce

error and its impact on all those involved in clinical incidents.

This publication has been produced by the Patient Safety Directorate, Performance

Activity and Quality Division, Department of Health, Western Australia, 2012.

All Rights Reserved. No part of this report may be reproduced in any form without written

permission of the copyright owners.

Patient Safety Directorate

Performance Activity and Quality Division

Department of Health, Western Australia

189 Royal Street EAST PERTH

Western Australia 6004

Telephone (08) 9222 0294

Web http://www.safetyandquality.health.wa.gov.au

The data presented is correct as of 29/7/2011.

Disclaimer

All information and content in this material is provided in good faith by the Department of

Health, Western Australia, and is based on sources believed to be reliable and accurate at

the time of development. The State of Western Australia, the Department of Health,

Western Australia and their respective officers, employees and agents, do not accept legal

liability or responsibility for the material, or any consequences from its use.

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Contents Definitions v

Executive summary 1

1. Introduction 6

2. Results 7

2.1 General overview 7

3. Top five principal incident type categories 11

3.1 Medication incidents 11

3.1.1 Quality improvement strategies to address medication incidents 17

3.1.2 Recommendations 18

3.2 Falls incidents 19

3.2.1 Quality improvement strategies to address falls incidents 24


3.3 “Other” incidents 25

3.3.1 Quality improvement strategies to address “other” incidents 30


3.4 Behaviour incidents 32

3.4.1 Quality improvement strategies to address behaviour incidents 37


3.5 Injury incidents 39

3.5.1 Quality improvement strategies to address injury incidents 45


3.6 Conclusion 46

4. Appendix A: CIMS outcome levels 48

Appendix B: Caveats 49

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Tables

Table 1 Top 10 medications involved in clinical incidents in WA (2010-11) 13

Table 2 Number and percent of medication incidents by contributory

factor (2010-11) 14

Table 3 Number and percent of falls incidents by type of contributory

factor (2010-11) 23

Table 4 Number and percent of “other” incidents by type of contributory

factor (2010-11) 29

Table 5 Number and percent of behaviour incidents by type of contributory

factor (2010-11) 35

Table 6 Number and percent of injury incidents by type of contributory

factor (2010-11) 44

Figures

Figure 1 Number and rate of clinical incidents notified per year (2001-11) 7

Figure 2 Clinical incidents by age group for (2010-11) 8

Figure 3 Clinical incidents by principal incident type (2010-11) 9

Figure 4 Clinical incidents by outcome level (2010-11) 10

Figure 5 Number and rate of medication incidents notified per year (2001-11) 11

Figure 6 Medication incident types (2010-11) 12

Figure 7 Medication incidents by outcome level (2010-11) 13

Figure 8 Number and rate of medication incidents by age group (2010-11) 16

Figure 9 Number and rate of falls incidents notified per year (2001-11) 19

Figure 10 Falls incidents by nature and location (2010-11) 20

Figure 11 Falls incidents by outcome level (2010-2011) 21

Figure 12 Number and rate of falls incidents by age group (2010-11) 22

Figure 13 Number and rate of “other” incidents notified per year (2001-11) 25

Figure 14 Type of “other” incidents (2010-11) 26

Figure 15 “Other” incidents by outcome level (2010-11) 27

Figure 16 Number and rate of “other” incidents by age group (2010-11) 28

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Figure 17 Number and rate of behaviour incidents notified per year (2001-11) 32

Figure 18 Type of behaviour incidents (2010-11) 33

Figure 19 Behaviour incidents by outcome level (2010-11) 34

Figure 20 Number and rate of behaviour incidents by age group (2010-11) 35

Figure 21 Number of behaviour incidents with alcohol or drug intoxication as a contributory factor (2001-11) 37

Figure 22 Number and rate of injury incidents per year (2001-11) 40

Figure 23 Type of injury incidents (2010-11) 41

Figure 24 Injury incidents by outcome level (2010-2011) 42

Figure 25 Number and rate of injury incidents by age group (2010-11) 43

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Definitions

Clinical Incident Management System (CIMS) – a database system developed by Patient Safety International for collecting and analysing information on clinical incidents. It covers voluntary reporting, investigating, analysing and monitoring of clinical incidents.

Bed days – the number of days a patient stays in hospital between admission and discharge. An aggregate measure of health service utilisation.

Clinical incident – an event or circumstance resulting from healthcare which could have, or did lead to unintended harm to a person, loss or damage. In the context of this report a „person‟ includes a patient, client or visitor.

Clinical incident management (CIM) – the process by which clinical incidents are notified, investigated, analysed and monitored for the purpose of improving patient safety and quality of healthcare.

Co-morbidities – the presence of one or more disorders (or diseases) in addition to a primary disorder or disease.

Contributory factor – a factor that contributes to the occurrence of an incident.

Harm – includes death, disease, injury, suffering and/or disability.

Healthcare associated infection – potentially preventable infections associated with hospitalisation.

Increased length of stay – a situation whereby a patient has to stay longer in hospital than would normally be expected.

Injury – in the context of CIM includes burns, injury due to an impact or collision, pressure ulcers, injury of unknown origin, unintended injury during a procedure or treatment, or other injuries not classifiable in the previous categories.

Minor outcome – an incident associated with minor harm to a patient not requiring treatment, but perhaps extra observations or monitoring. Refers to Outcome Level 4 in CIMS, see appendix A.

Moderate outcome – an incident associated with a moderate level of harm to the patient requiring review by a doctor and minor diagnostic investigations or treatment (e.g. x-ray, blood tests, analgesia, and minor dressings). Refers to Outcome Level 5 to 6 in CIMS, see appendix A.

Near miss – is an incident that may have, but did not cause harm, either by chance or through timely intervention.

Outcome – end result or consequence of an incident to the patient.

v

Outcome level – one of eight levels of consequence assigned to clinical incidents in CIMS, primarily denoting severity of the incident to the patient, client or visitor (see Appendix A).

Pathophysiological factors – factors associated with disease.

Principal Incident Type (PIT) – the category into which a clinical incident reported to CIMS is classified. There are a total of ten PIT categories which include:

Behaviour;

Blood, oxygen or gas;

Documentation;

Fall;

Injury;

Medication;

Nutrition;

Safety and security;

Therapeutic devices or

equipment; and

Other.

Root Cause Analysis (RCA) – a systematic investigative technique aimed at identifying root causes/contributory factors of problems, events or incidents.

Safety and Quality Investment for Reform (SQuIRe) – the Safety and Quality Investment for Reform (SQuIRe) Program was established in July 2006 to strengthen the Department of Health, Western Australia‟s clinical governance and patient safety management systems, and to ensure the delivery of safe, high quality, evidence-based healthcare to patients and the WA community.

Sentinel event – notified rare events that lead to catastrophic patient outcomes.

Separations – signifies the end of an episode of care (single or multi-day) and is a common unit to measure activity.

Severe outcome – an incident associated with severe or catastrophic harm to a patient (permanent disability or death). Refers to Outcome Level 8 in CIMS, see appendix A.

Significant outcome – an incident associated with a significant level of harm to a patient. Refers to Outcome Level 7 in CIMS. Examples include an incident resulting in an increased length of stay in hospital, admission to hospital, readmission to hospital, transfer to an intensive care unit, resuscitation, secure ward management, seclusion, fractured neck of femur, or morbidity which continued at discharge.

SQuIRe Clinical Practice Improvement (CPI) Program – the SQuIRe Clinical Practice Improvement (CPI) Program supports the implementation of practices that improve patient outcomes. There are eight CPI initiatives grouped in three clusters: Cluster 1 evidence based clinical practice; Cluster 2 medication reconciliation, and; Cluster 3 infection control practices.

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Executive summary

This report documents the key features and trends of the top five clinical incident types

notified to the Clinical Incident Management System (CIMS) in Western Australia

between 1 July 2010 and 30 June 2011. The CIMS is a voluntary clinical incident

reporting system and is just one of several systems used by WA Health to capture and

manage clinical incidents and adverse events.

The process of clinical incident management (CIM) enables changes to be implemented

at the clinical service delivery level to prevent future incidents from occurring and to

improve patient safety.

There are ten principal incident types (PIT). This report documents key trends in the five

most frequently reported PIT‟s which represent 84.1% (n=17 973) of all notified incidents

for this time period.

General overview of clinical incidents 2010 to 2011

At the time of data analysis there were 229 810 incidents contained in the CIMS

database. The rate of clinical incidents for this year was calculated at 13 incidents per

1 000 bed days, which is a lower rate than observed in the 2009-10 period (17.5 per 1

000 bed days). In 2010-11 there were 467 237 separations from hospital, with clinical

incidents associated with 4.5% of hospital separations.

A total of 21 487 incidents were reported and classified in CIMS during the 2010-11

financial year. This is a substantial decrease from 2009-10 where 28 067 clinical

incidents were reported into the CIMS. Decreases in incident reports were observed in

the months of May and June 2011. One reason for this decrease may be attributed to a

change in Commonwealth qualified privilege protection afforded to the investigation and

analysis of clinical incidents, which ceased on June 9th 2011. However, WA Health has

also been responsible in implementing numerous State-wide and site specific quality

improvement projects to reduce the occurrence of clinical incidents.

Findings revealed that elderly patients aged 65 years or more were involved in the

majority (50.6%; n=10 881) of reported clinical incidents. Medication and falls incidents

continue to be the most frequently reported, followed by those captured in the “other”

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incidents, behaviour incidents, and injury categories. The majority (58%; n=12 374) of

clinical incidents were classified with an outcome level of 3 or 4, referring to incidents

resulting in no harm or minor harm to the patient. In 2010-11, 47 incidents (0.2%) were

classified with a Level 8 outcome (severe harm resulting in permanent disability or

death).

Top five clinical incidents findings

Medication incidents

Medication incidents account for the highest proportion (24%; n=5 055) of incidents

reported to the CIMS for this time period, with a downward trend observed (4.6

incidents per 1 000 bed days in 2008-09 to 3.0 incidents per 1 000 bed days in 2010-

11).

Medication omissions (n=1 381) and medication overdoses (n=1 000) were the most

frequently observed types of medication errors observed in 2010-11.

Analgesics, insulin preparations and anticoagulants were the most frequently

reported medications associated with clinical incidents.

Less than one percent of incidents (0.7%; n=34) were associated with significant or

severe harm (Level 7 or 8 incidents).

Using a multiple response format, 10 224 contributing factors were identified as

being associated with medication incidents. The largest proportion of medication

incidents occurred as a result of either “failing to follow policy/procedure” (30.5%;

n=3 117) or “failure to read or misreading” (19.8%; n=2 023).

The number of reported medication incidents was shown to increase with age.

However, the highest rate of medication incidents occurred in the 10-14 year age

group with 5.1 incidents per 1 000 bed days observed.

Falls incidents

Falls were the second most frequently reported clinical incident for this time period

representing 22.8% (n=4 911) of all incidents reported. Since 2005-06 the rate of

incidents has continued to track downward from 5.0 to 3.0 falls incidents per 1 000

bed days in 2010-11.

Two percent (n=120) of all falls incidents were associated with significant

(Level 7) to severe harm (Level 8). One patient death resulted from a fall.

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The majority of falls reported were sustained by patients aged 65 years or more

(73.5%; n=3 613). Twenty nine (0.6%) falls incidents resulted in either a dislocation

or fracture.

The rate of falls was highest in patients aged 85 years or more (7.6 falls per 1 000

bed days calculated).

Using a multiple response format, the two most frequently reported contributory

factors associated with falls were attributed to patient pathophysiological factors

(21.4%; n=2 432) and physical impairment factors (17.5%; n=1 995).

Incidents classified as “other”

There were 3 488 “other” incidents notified to the CIM database.

For this “other” category, no, wrong or delayed procedure, treatment or assessment

accounted for 62.4% (n=2 176) of incidents in 2010-11.

Since 2008-09, “other” incidents have been observed to decrease from a rate of 2.6

incidents per 1 000 bed days to 2.1 incidents per 1 000 bed days in 2010-11.

The majority (53%; n=1 875) of incidents caused no/minimal harm (Level 3 or 4).

In 2010-11, 29 incidents were classified as a Level 8 incident with 27 incidents

resulting in death of a patient.

The incidence rate for “other” incidents was observed to decrease with age. In 2010-

11 the rate of incidents in this category was highest in the 20-24 year age group

(3 incidents per 1 000 bed days) declining to a rate of 1.4 for those over 85 years.

The three most common contributory factors for incidents classified as “other” were

communication problems (20%; n=1 229), failure to follow policy or procedure

(16.4%; n= 1 008) or pathophysiological factors (10.9%; n=669).

Behaviour incidents

There were 2 482 behaviour incidents notified into CIMS. Behaviour incidents were

observed to have halved from 3.1 incidents in 2008-09 to 1.5 incidents per 1 000 bed

days reported in 2010-11.

Physical/verbal abuse, aggression, assault or absconding accounted for 50%

(n=1 209) of behaviour incidents reported over this time period.

Forty percent (n=995) of behaviour incidents resulted in moderate harm (Level 5 or

6) to the patient. Ten (0.4%) Level 8 incidents were due to self inflicted harm.

4

Sixty three percent (n=1 576) of behaviour incidents occurred in a mental health

facility.

In 2010-11, the rate of behaviour incidents peaked in the 15-19 year age group with

a rate of 5.2 behaviour incidents per 1 000 bed days observed.

The main factors identified as contributing to behaviour incidents, included mental

health factors (40%; n=1 559), dementia (8.6%; n=336), and pathophysiological

factors (8.5%; n=332).

Injury incidents

Overall injury incidents represented 9.4% of all notifications to the system for this

time period, with 2 037 injury incidents notified to CIMS.

The rate of injury incidents has decreased slightly from 1.8 incidents in 2008-09 to

1.4 incidents per 1 000 bed days in 2010-11.

Less than 2.5% (n=50) of injury incidents in 2010-11 resulted in an outcome Level of

7 while one incident in this same time period was given an outcome Level of 8 which

resulted in severe harm.

The number and rate of injury incidents increased with age over time with the highest

injury rate occurring in those aged 85 years or older (2.9 injuries per 1 000 bed

days).

In 2010-2011, 28.5% (n=581) of injury incidents were pressure ulcers with 3.8%

(n=22) of these classed as stage 3 pressure ulcers (referring to full thickness skin

loss involving damage or necrosis of subcutaneous tissue that may extend down to,

but not through, underlying fascia).

The two most frequently reported contributory factors associated with injury incidents

were attributed to pathophysiological factors (n=1 071) or physical impairment

factors (n=633).

Conclusion

WA Health continues to make substantial improvements in preventing and reducing

clinical incidents across the State as evidenced by the rate reduction observed for

medication, falls, “other”, behaviour and injury clinical incidents. This success can be in

part attributed to the comprehensive quality improvement projects and programs that

have been implemented by both State and Area Health Services and the significant

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efforts of Safety and Quality staff and their clinical colleagues in achieving these

improvements are to be acknowledged and applauded. Further improvements in clinical

incident management have also included the release of the new Clinical Incident

Management (CIM) Policy in September 2011. This new CIM policy introduced to WA

Health, both an integrated CIM policy as well as the severity assessment codes (SAC).

The SAC are three codes (1, 2 or 3) used to determine the appropriate level of analysis,

action and escalation to assess the consequences associated with a clinical incident.

SAC 1 includes all clinical incidents/near misses where serious harm or death is/could be

specifically caused by health care rather than the patient‟s underlying condition or illness.

In WA, SAC 1 also includes the eight nationally endorsed sentinel event categories.

SAC 2 includes all clinical incidents/near misses where moderate harm is/could be


SAC 3 includes all clinical incidents/near misses where minimal or no harm is/could be


The implementation of SAC codes will also assist in the refinement of future CIM reports

by allowing clinical incident data to be presented by the severity of harm sustained by the

patient. This report also identifies areas within CIM that would benefit from greater

targeting of quality improvement activities, these include:

Medication omissions and overdoses;

Analgesics particularly paracetamol, insulin preparations and anticoagulants;

Identifying contributory factors associated with medication incidents in children

aged 0-14 years, in order to develop targeted prevention strategies;

Developing falls strategies specifically targeting those aged 85 years or more;

Strategies to reduce falls incidents resulting in fractures;

Enhancing behaviour strategies targeting those in the 10-39 year age group;

Continue to implement strategies that address such issues as behaviour

management, alcohol and drug intoxication and physical abuse/aggression

Strategies to reduce “No, wrong or delayed” procedure incidents;

Enhancing communication in health care delivery; and

Continuing to implement programs that address pressure ulcer prevention.

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1. Introduction

This report provides a summary analysis of clinical incidents which have been identified,

reported and addressed by staff working throughout WA Health during the period of

1 July 2010 to 30 June 2011. Specifically, this report documents key trends in the five

most frequently reported PIT, which represent 84% (n=17 973) of all notified incidents for

this time period.

Clinical incident management which utilises the CIMS database is a voluntary reporting

system whereby staff, patients, clients, carers or visitors who witness a clinical incident

are encouraged to report the incident. Once notification of an incident occurs it is then

investigated, analysed, classified and recommendations identified which are then

implemented and evaluated. It is only through this constant monitoring that patient safety

issues can be identified and addressed, with lessons learned shared across the

healthcare system.

The CIMS has been in place throughout WA Health services since October 2001. At the

time of writing, all public hospitals/health services and one private hospital in WA use the

AIMS version 2.4 software system.

The CIMS is one of several reporting systems used by WA Health to capture clinical

incidents and facilitates the notification, investigation, analysis and monitoring of the

clinical incidents that occur in both public inpatient and outpatient healthcare settings.

Communication remains a key component to improving safety and quality in healthcare.

This report seeks to inform the Western Australian community of incidents that have

occurred within our health system and the measures that are taken to prevent their

recurrence.

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2. Clinical Incident Management Findings 2010-11

2.1 General overview

In 2010-11, 21 487 incidents were reported, which is a decrease from 2009-10

(n=28 067). For this same time period there was an increase in hospital separations

(n= 476 237) compared to 468 746 hospital separations in 2009-10.

Clinical incidents were associated with 4.5% (n=21 487) of hospital separations in 2010-

11 while in 2009-10 a slightly higher figure of 5.9% (n=28 067) was observed. The rate of

clinical incidents for the 2010-11 period was calculated at 13 incidents per 1 000 bed

days which is a considerable decline compared to the 2009-10 period (17.5 per 1 000

bed days; see Figure 1).

Figure 1 Number and rate of clinical incidents notified per year (2001-11)*

*Implementation of CIMS commenced in October 2001, therefore data for 2001-02 is not for a full year.

There was no significant difference in gender proportions for clinical incidents observed

in 2010-11 (female n=10 205; male n=9 907; missing data n= 1375). In 2010-11, nurses

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were the main reporters of clinical incidents (74.3%; n=15 959) followed by medical

officers (4.9%; n=1052) and allied health staff (4.1%; n=881).

Patient‟s ages ranged from 0 years to 105 years with a mean age of 57 years (SD 26

years). Elderly patients aged 65 years or more were involved in the majority (50.6%;

n=10 881) of clinical incidents reported, with patients aged over 85 years being involved

in more clinical incidents (14.5%; n=3 105) than other age groups (see Figure 2).

Figure 2 Clinical incidents by age group (2010-11)

The frequency of incidents categorised by PIT is shown in Figure 3. Medication and falls

incidents continue to be the most frequently reported followed by those captured in the

“other” incidents PIT category, behaviour incidents, and injury incidents. The “other” PIT

category includes:

Medical emergency;

No, wrong or delayed procedure, treatment or assessment;

No or delayed admission, inappropriate bed or ward;

No or wrong or delayed diagnosis;

Wrong patient, body part or side ;

Poor discharge planning ;

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Hospital acquired infection; and

Other (e.g. lost/incorrectly/ transported or stored specimens, surgical complications).

Figure 3 Clinical incidents by principal incident type (2010-11)

Once a clinical incident is notified it is investigated by the health service where the

incident occurred (see the Clinical Incident Management Policy). On completion of the

investigation, incidents are then classified according to the severity of the outcome to the

patient on a scale of 1-8 (see Appendix A).

Outcome level/s of:

1-2 are defined as a „near miss‟ resulting in no harm to the patient;

3-4 refer to events resulting in no harm or minor harm, respectively;

5-6 refer to moderate harm occurring;

7 is defined as significant harm having occurred (e.g. resulting in increased length of

stay, admission or readmission to hospital, seclusion, transfer to ICU, resuscitation,

fractured neck of femur or transfer to another hospital); and

8 refers to severe harm resulting in permanent disability or death.

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Figure 4 shows that the majority of clinical incidents (60%; n=12 801) were classified as

having caused no harm or minimal harm (Level 1- 4) to the patient. For incidents which

resulted in significant harm, there were 1 277 Level 7 incidents (5.9%) reported in 2010-

11, while there were 0.2% (n=47) incidents classified with an outcome Level 8.

Figure 4 Clinical incidents by outcome level (2010-11)*

*Missing data n=96.

Of the 1 324 Level 7 and 8 incidents reported for 2010-11, behaviour incidents were the

most frequently reported clinical incident (55%; n=729) followed by clinical incidents

classed in the “other” category (n=325).

The three most frequently reported types of Level 7 behaviour incidents for 2010-11

included physical abuse, aggression or assault (n=564), inappropriate behaviour (n=74)

and verbal abuse or aggression (n=26). These three types of behaviour incidents

accounted for 91% of all Level 7 behaviour incidents. The most frequently reported Level

8 behaviour incident in 2010-11, was suicidal behaviour (n=10). For 2010-11, the overall

rate of clinical incidents was 13 per 1 000 bed days, while the frequency of clinical

incidents resulting in permanent disability or death was 47 incidents for this same time

period.

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3. Top five principal incident type categories

The following section will concentrate on the five most frequently reported PIT categories

which represent 84% (n=21 487) of all clinical incidents reported during the 2010-11

period. The PIT categories reported in this section include:

1. Medication incidents;

2. Falls incidents;

3. “Other” incidents;

4. Behaviour incidents; and

5. Injury incidents.

3.1 Medication incidents

Between 1 July 2010 and 30 June 2011 there were 5 055 medication incidents notified,

which is a 22% (n=1 453) decrease in medication incidents reported in 2009-10

(n=6 508). Medication incidents have continued to be one of the top two most frequently

notified types of clinical incident since 2001. Between 2008-09 and 2010-11 there has

been a downward trend in the number and rate of reported incidents with the rates

ranging from 4.6 to 3.0 incidents per 1 000 bed days (see Figure 5).

Figure 5 Number and rate of medication incidents notified per year (2001-11)


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Medication omissions (n=1 381) and medication overdoses (n=1 000) were the most

frequently observed types of medication errors in 2010-11 and accounted for 47% of all

medication incident types (see Figure 6).

Figure 6 Medication incident types (2010-11)

* Other includes: Damaged product, expired medication, reaction to medication, self inflicted overdoses,

wrong frequency/infusion rate/route, no or incorrect labelling, problem during therapeutic use, theft or loss.

**Wrong medication additive or fluid.

Medications involved in clinical incidents were ranked according to the frequency of

reporting. Table 1 shows that in 2010-11, analgesics, insulin preparations and

anticoagulants were the most frequent medications involved in medication incidents.

This group of medications accounted for 10.9% (n=552) of all medication incidents in

2010-11. Paracetamol continues to be one of the top three medications involved in

medication incidents reported since 2003-04.

Given but not

signed for

Given without order

Wrong med**

Omitted Other meds

involved

Over dose

Under dose

Wrong patient

Wrong time

Other*

2010-11 143 158 667 1381 757 1000 197 112 172 468

0

200

400

600

800

1000

1200

1400

1600

Nu

mb

er

of

incid

en

ts

13

Table 1 Top 10 medications involved in clinical incidents in WA (2010-11)

Rank Medication Medication class No. of incidents

1 Paracetamol Analgesic 236

2 Insulin Insulin Preparation 160

3 Enoxaparin sodium Anticoagulant 156

4 Warfarin sodium Anticoagulant 127

5 Oxycodone Opioid Analgesic 115

6 Morphine Opioid Analgesic 100

7 Heparin Anticogulant 99

8 Oxycodone

hydrochloride

Opioid Analgesic 94

9 Frusemide Diuretic 82

10 Tramadol Analgesic 76

Total 1 245

Over 52% of all reported medication incidents were classified as level 3 incidents which

resulted in no harm to the patient (see Figure 7). Less than one percent of medication

incidents in 2010-11 (0.6%, n=34) were associated with significant or severe harm

(Level 7 or 8 incidents). One death resulting from a medication incident (reaction to

medication) was reported in 2010-11.

Figure 7 Medication incidents by outcome level (2010-11)*

*Missing data n=21

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Contributory factors were classified into three categories; staff, patient and system

factors (see Table 2). Using a multiple response format, several contributory factors

were identified for each incident. In total there were 10 224 contributory factors

associated with the 5 055 medication incidents notified in 2010-11. Results showed that

staff contributory factors accounted for 92.3% (n=9 433) of factors followed by patient

contributory factors (6.4%; n=649) and system contributory factors (1.3%; n=142).

Table 2 shows that in 2010-11, 30.5% (n=3 117) of medication incidents were caused by

staff failing to follow policy/procedure while failing to read or misreading accounted for

19.8% (n=2 023). Results also showed that pathophysiological factors affecting patients

contributed to 38.7% (n=251) of medication incidents (see table 2).

Table 2 Number and percent of medication incidents by contributory factor for (2010-11)*

Staff contributory factors

2010-11

(n) % Contributory factors for medication incidents

Failure to follow policy or procedure 3117 30.5%

Misread or did not read documentation 2023 19.8%

Inadequate knowledge or inexperience 931 9.1%

Communication problem 798 7.8%

Other 632 6.2%

Distraction or inattention 572 5.6%

Poor teamwork or supervision 566 5.5%

Fatigue or stress or unwell 291 2.8%

Multiple staff or poor continuity 207 2.0%

Failure to follow advice or instructions 130 1.3%

Insufficient or inadequate staff 111 1.1%

Pressure to proceed 23 0.2%

Medication not reviewed 17 0.2%

Staff did not attend when required 10 0.1%

No PRN medications ordered 3 0.0%

PRN medications not used 2 0.0%

Sub total 9 433 92.3%

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Table 2 Number and percent of medication incidents by contributory factor

(2010-11)* continued*

Patient contributory factors (n) (%) Pathophysiological factors 251 2.5%

Other 208 2.0%

Mental health related 51 0.5%

Confusion or disorientation 33 0.3%

Failure to follow advice or instructions 33 0.3%

Dementia 27 0.3%

Language or speech barrier 20 0.2%

Physical impairments 9 0.1%

Affected by medication 6 0.1%

Very ill, frail, debilitated or general deterioration 4 0.0%

CVA or TIA 3 0.0%


Alcohol or drug intoxication 2 0.0%

Sub total 649 6.3%

System contributory factors (n) (%)

Other 134 1.3%

Environment hazard or hazardous 6 0.0%

Security problem 2 0.0%

Sub total 142 1.3%

Total 10 224 100.0%

* An incident can be associated with more than one contributory factor.

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The highest rate of medication incidents occurred in the 10-14 year age group with 5.1

incidents per 1 000 bed days observed (see Figure 8). The lowest rate of medication

incidents occurred in 15-19 year age group with 2.0 incidents per 1 000 bed days

observed. The frequency of medication incidents was shown to increase in the older age

groups.

Figure 8 Number and rate of medication incidents by age group (2010-11)*

*Missing data n=278

Further examination of the 0-14 year age groups revealed that most of the medication

incidents were either due to medication omissions (26.1%; n=121) or medication

overdoses (23.1%; n=107). The majority of medication incidents resulted in no harm or

minor harm to the patient (80.4%; n=373). However, four incidents did result in

significant or severe harm to the patient. The main contributing factors in these incidents

were failing to follow policy or procedure (37.4%; n=223) or misreading or didn‟t read the

documentation (25.5%; n=152).

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3.1.1 Quality improvement strategies to address medication incidents

Both State and Area Health Services have developed and implemented strategies to

decrease the number of medication incidents. Examples of some of the quality

improvement strategies implemented include: *

Routine medication reconciliation, which is the formal process of obtaining and

verifying a complete and accurate list of each patient's current medicines,

matching the medicines the patient should be prescribed to those they are

actually prescribed;

Regular chart reviews, and, in particular, compliance with daily checking of

schedule four and eight medications;

Provision of education and training to ensure that intramuscular injection practices

are evidence based;

Development and implementation of a Patient‟s Own Medication form and sticker.

Distribution of national patient safety medication information to improve

medication safety awareness;

Improving the quality and accuracy of the electronic patient discharge summary

by making enhancements to the application;

Training clinical pharmacists on the use of the psychiatric services on-line

information system software to retrieve and document information and update

allergy and adverse drug reaction information;

Staff education on the recognition of error-prone situations, potential

complications, contraindications and drug interactions;

Improved discharge processes such as communication with general practitioners

and other health care specialists;

The introduction of medication safety groups to oversee governance of medication

safety;

A project targeting medication errors (omissions) which resulted in changes to the

routine checking of medication charts;

Introduction of a new Anticoagulation Service Referral Form to provide a more co-

ordinated approach to managing Warfarin therapy pre and post procedure;

Review of patient documentation to determine the incidence of adverse events

that may be attributed to intravenous paracetamol;

18

Prevalence survey of the appropriateness of antibiotic use. This includes whether

antibiotic use was indicated, in addition to whether the choice and use of antibiotic

(dose, frequency, route administration and duration) was correct;

Audit of unacceptable abbreviations used on medication charts;

Provision of “quick flick” medication reference cards for easy access of medication

information; and

Review of muscle relaxant anaphylaxis and assessment of individual drug

allergenicity and cross-reactivity.

*Please note that this list of strategies used to address patient safety within WA Health is not exhaustive with only a small number of quality improvements strategies listed.

3.1.2 Recommendations

While there are numerous quality improvement projects/programs being implemented

throughout WA Health, results from this annual report have identified clinical incident

areas which would benefit from additional targeting, if further reduction in medication

clinical incidents are to be achieved. These include quality improvement projects

addressing:


Analgesics particularly paracetamol, insulin preparations and anticoagulants; and


aged 0-14 years, in order to develop targeted prevention strategies.

19

3.2 Falls incidents

From 1 July 2010 to 30 June 2011 there were 4 911 falls notified, representing 22.8% of

all incidents for the period.

Falls incidents continue to be one of the most notified incidents reported per year. Since

2005-06 the rate of incidents has continued to show a downward trend from 5.0 to 3.0

falls incidents per 1 000 bed days in 2010-11.

Since 2001, falls incidents have consistently been one of the most notified incidents

reported per year. There has been a continuing downward trend in both the number and

rate of falls since 2005-06 (see Figure 9) from 5.0 to 3.0 falls per 1 000 bed days in

2010-11.

Figure 9 Number and rate of falls incidents notified per year (2001-11)*


20

In 2010-11, 24% (n=1 220) of all falls reported were associated with a fall on the same

level, for example while walking or standing (see Figure 10).

Figure 10 Falls incidents by nature and location (2010-11)

The majority of falls (45%, n=2 227) were associated with minor harm (Level 4, see

Figure 11).

Two percent (n=120) of all falls incidents for 2010-11 were associated with significant

(Level 7 outcome) to severe harm (Level 8 outcome). These types of incidents include,

for example, incidents resulting in a fractured or dislocated neck of femur, transfer to the

intensive care unit, an increased length of stay in hospital, permanent disability or death.

21

Figure 11 Falls incidents by outcome level (2010-2011)*

*Missing data n=33

Of the 4 911 fall incidents in 2010-11, 0.6% (n=29) resulted in a fracture. The majority

(72.4%; n=21) of patients sustained a fractured neck of femur with the remainder

sustaining fractures to the wrist, lumbar or pubic ramus. One death occurred post fall.

22

The majority of falls were sustained by patients aged 65 years or more (73.5%;

n=3 613). The highest rate of falls incidents occurred in the 85+ year age group with 7.6

incidents per 1 000 bed days observed (see Figure 12).

Figure 12 Number and rate of falls incidents by age group (2010-11)

Several contributing factors were identified for each falls incident. In total there were

12 277 contributing factors associated with the 4 911 falls incidents notified in 2010-11.

Results showed that patient contributing factors accounted for 92.6% (n=11 370) of

factors followed by staff contributing factors (5.1%; n=621) and system contributing

factors (2.3%; n=286).

Results showed that pathophysiological factors affecting patients accounted for 21.4%

(n=2 432) of falls incidents (See Table 3).

23

Table 3 Number and percent of falls incidents by type of contributory factor (2010-11)*

Staff contributory factor

2010-11

(n) % Contributory factors for falls

incidents


Other 97 0.8%

Communication problem 91 0.7%



Failure to follow policy or procedure 56 0.5%

Inadequate knowledge or

inexperience 54 0.4%

Failure to follow advice or

instructions 44 0.4%



Misread or did not read

documentation 3 0.0%


Sub total 618 5.1%

Patient contributory factors (n) (%)

Pathophysiological factors 2 432 21.4%

Physical impairments 1 995 17.5%

Other 1 438 12.6%

Failure to follow advice or

instructions 1 426 12.5%

Confusion or disorientation 1 185 10.4%

Dementia 789 6.9%

Unsteady on feet 412 3.6%

Very ill, frail, debilitated or general

deterioration 413 3.6%

Wrong or no footwear 335 2.9%


CVA or TIA 308 2.7%


Language or speech barriers 106 0.9%



Sub total 11 370 92.6%

24

Table 3 Number and percent of falls incidents by type of contributory factor (2010-11) continued*

*An incident can be associated with more than one contributory factor.

3.2.1 Quality improvement strategies to address falls incidents


decrease the number of falls incidents. Some project examples include:*

Implementation of the State-wide SQuIRe Falls Prevention Initiative;

Active participation of health services in the SQuIRe Falls Clinical Practice

Improvement (CPI) initiative and the Falls Prevention Network;

Implementation of a State-wide standardised Falls Risk Management Tool with

agreement on a WA Audit Tool;

Review of falls prevention and harm minimisation activities;

Team reviews which include the family/resident involved in multiple fall incidents;

Development of a fractured neck of femur pathway;

Appropriate utilisation of non slip socks for the prevention of falls;

Education and up skilling of nurses on the falls risk; and

Targeted falls program focussing on patients identified as at risk of falling.





areas which would benefit from greater targeting, if further reduction in falls is to be

achieved. These include:

Focussing on reducing the falls in elderly patients aged 85 years or more; and

Strategies to reduce Level 7 and 8 incidents, with a focus on falls resulting in

fractures.

System contributory factors (n) (%) Environmental hazard or hazardous

environment 176 61.5%

Other 99 34.6%

Call bell or paging problem 8 2.8%

Security problem 3 1.0%

Sub total 286 2.3%

Total 12 277 100.0%

http://www.healthnetworks.health.wa.gov.au/projects/falls_risk.cfm

25

3.3. “Other” incidents

Between 1 July 2010 and 30 June 2011 there were 3 488 “other” incidents notified to the

CIM database. A significant number of clinical incidents do not fit within the defined nine

PITs and are categorised as “other” incidents which includes:

Medical emergency;

No, wrong or delayed procedure, treatment or assessment;

Other (e.g. lost/incorrectly transported or stored specimens, surgical

complications);

No or delayed admission, inappropriate bed or ward;

Poor discharge planning;

Hospital acquired infection;

No or wrong or delayed diagnosis; and

Wrong patient, body part or side.

Since 2008-09 there has been a downward trend in “other” incidents reported (see

Figure 13).

Figure 13 Number and rate of “other” incidents notified per year (2001-11)*

*Implementation of CIMS was commenced in October 2001, therefore data for 2001-02 is not for a full year.

26

The category no, wrong or delayed procedure, treatment or assessment accounted for

the majority of “other” incidents (62.4%; n=2 176) observed in 2010-11 (see Figure 14).

Figure 14 Type of “other” incidents (2010-11)

* Refers to no, wrong or delayed procedure, treatment or assessment. ** Refers to no or delayed admission, inappropriate bed or ward. *** Refers to wrong patient or body part/side.

Over 53% (n=1 875) of “other” incidents resulted in no harm or minor harm (Level 3 or

4). However a total of 354 incidents (10.2%) were categorised as resulting in significant

(Level 7) or severe harm (Level 8) to the patient (see Figure 15). Twenty seven

incidents resulted in death of the patient.

27

Figure 15 “Other” incidents by outcome level (2010-11)*

*Missing data n=19

In 2010-11 the rate of “other” incidents was shown to peak at 3.0 incidents per 1 000 bed

days in those aged 20-24 years after which the rate of incidents was shown to then

decrease with age (see Figure 16).

28

Figure 16 Number and rate of “other” incidents by age group (2010-11)*

*Missing data n=221

In 2010-11, staff factors were identified as contributing to be the majority of “other

incidents” (74.1%; n=4 557). Communication problems (20.0%; n=1229) and failure to

follow procedure (16.4%; n=1 008) accounted for over a third of contributory factors (see

Table 4).

29

Table 4 Number and percent of “other” incidents by type of contributory factor for (2010-11)*

Staff contributory factors Number of “other”

incidents

% Contributory factors for

“other” incidents Communication problem 1 229 20.0%

Failure to follow policy or procedure 1 008 16.4%

Inadequate knowledge or inexperience

658 10.7%

Other 438 7.1%



Failure to follow advice or instructions

185 3.0%

Misread or did not read documentation

154 2.5%





Pressure to proceed 29 0.5%

Medication not reviewed 1 0.0%

Sub total 4 557 74.1%

Patient contributory factors (n) (%)

Pathophysiological factors 669 10.9%

Other 170 2.8%


Failure to follow advice or instructions

38 0.6%

Language or speech barriers 37 0.6%

Physical impairments 37 0.6%


Very ill, frail, debilitated or general deterioration

24 0.4%

Confusion or disorientation 19 0.3%

Cerebral vascular accident 10 0.2%

Dementia 9 0.1%


Unsteady on feet 4 0.1%

Sub total 1 116 18.2%

30

Table 4 Number and percent of “other” incidents by type of contributory factor (2010-11) continued*

System contributory factors (n) (%)

Other 449 7.3

Environmental hazard or hazardous environment

14 0.2

Call bell or paging problem 4 0.1

Security problem 2 0.0

Sub total 469 7.7%

Total 6142 100.0% *An incident can be associated with more than one contributory factor.

3.3.1 Quality improvement strategies to address “other” incidents


decrease the number of “other” incidents. Project examples include:*

WA Health participation in the national hand hygiene initiative to reduce

healthcare associated infections in public hospitals;

SQuIRe Hand Hygiene environmental audits and staff knowledge surveys

undertaken in 95% of wards with sites actioning recommendations as required;

Development and implementation of the WA Adult Observation and Response

Chart for recognising and responding to clinical deterioration;

Prevention of surgical site infections (SQuIRe project);

WA Health developed and implemented the WA Health Surgical Safety Checklist

through extensive stakeholder consultation, to improve surgical safety;

Compliance with elements of Central Venous Line (PICC) practice and

maintenance of lines documented in the current Clinical Practice Guidelines;

Establishment of an After Hours Nurse Manager to provide after hours support for

emergencies;

Recruitment of an infection control link nurse to ensure infection control practices

are contemporary;

Introduction of patient journey boards to improve discharge planning;

Clinical Risk Assessment and Management (CRAM) implementation of a State-

wide risk assessment tool to ensure the efficient and effective communication of

risk and risk management plans - Oct 2010;

“T Party” committee established to oversee the implementation and evaluation of

emergency triage changes;

31

The establishment of the Clinical Handover of General Medicine Group (CHOGM)

to oversee improvements in clinical handover;

The establishment of the Logical Information Made Easy tool (LIME) which was

developed to improve communication with telephone requests for medical

reviews;

Introduction of the partogram record audit process to monitor the standard of

documentation used to monitor maternal labour;

Implementation of the STOPS (Spreading the Outcomes of Patient Safety) Report

to share lessons and other patient safety and quality information;

Introduction of hand gel at the patient bed side to reduce infection risk; and

Enhancing the electronic discharge summary application to improve the quality

and accuracy. * Please note that this list of strategies used to address patient safety within WA Health is not

exhaustive with only a small number of quality improvements strategies listed.




areas which would benefit from greater targeting, if further reductions in “other” clinical

incidents are to be achieved. These include strategies focusing on:

Reducing “No, wrong or delayed” procedures; and

Enhancing communication in healthcare delivery.

32

3.4 Behaviour incidents

Between 1 July 2010 and 30 June 2011 there were 2 482 (11.6%) behaviour incidents

notified into the CIMS database. This is a 49% decrease compared with 2009-10 when

4 880 behaviour incidents were notified.

Between 2001-02 and 2008-09 behaviour incidents demonstrated an upward trend in the

number and rate of incidents reported. From 2009-10 the number and rate of behaviour

incidents has shown a dramatic downward trend from 3.1 incidents to 1.5 incidents per

1 000 bed days reported in 2010-11 (see Figure 17).

Figure 17 Number and rate of behaviour incidents notified per year (2001-11)*

*Implementation of CIMS was commenced in October 2001, therefore data for 2001-02 is not for a full year.

Behaviour incidents can be classified into ten subcategories (see Figure 18). The most

commonly reported behaviour incident for 2010-11, which accounted for almost 50% of

incidents, was physical abuse, aggression or assault (n=1 209).

33

Figure 18 Type of behaviour incidents (2010-11)*

*Physical abuse, aggression or assault.

In 2010-11, the behaviour incidents which resulted in no harm to the patient accounted

for 30% (n=744 Level 1-4) of incidents while moderate harm (Level 5 or 6) accounted for

40% (n=995) of incidents.

The remainder (n=740) of behaviour incidents resulted in either significant harm or

severe harm to the patient (Level 7 or 8; see Figure 19). The most commonly reported

Level 7 behaviour incidents were physical abuse, aggression or assault (n=564).

Results showed that death by suicide accounted for all Level 8 (n=10) incidents reported

during this period.

0

200

400

600

800

1000

1200

1400

Behaviour type

Nu

mb

er o

f in

cid

en

ts

2010-11 370 221 19 177 234 27 1209 16 47 162

AbscondingInappropriate

behaviour

Inappropriate

sexual

behaviour

Intended self

harm

Non-

compliance

Other

behaviour

Physical

abuse,

aggression

Self

discharge

Suicidal

behaviour or

attempted

Verbal abuse

or

aggression

34

Figure 19 Behaviour incidents by outcome level (2010-11)*

*Missing data n=5

In 2010-11, 1 576 behaviour incidents were reported as occurring in a mental health

facility. This equates to 63% of all behaviour incidents reported. While for the same time

period, Emergency Departments (EDs) notified 144 behaviour incidents which equates to

5.8% of all behaviour incidents reported. This is a substantial decrease compared to

2009-10 when EDs notified 17.8% (n=871) of behaviour incidents.

In 2010-11 the 15-19 year age group reported the highest rate of behaviour incidents

with 5.2 behaviour incidents per 1 000 bed days observed (see Figure 20). The 35-39

year age group reported the highest number of behaviour incidents (n=334).

0

100

200

300

400

500

600

700

800

Outcome level

Nu

mb

er

of

incid

en

ts

2010-11 1 5 404 334 705 290 730 10

Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7 Level 8

35

Figure 20 Number and rate of behaviour incidents by age group (2010-11)

In 2010-11 patient contributory factors were most commonly reported factors resulting in

behaviour incidents, with mental health factors accounting for 40% (n=1 559) of incidents

(see Table 5).

Table 5 Number and percent of behaviour incidents by contributory factor (2010-11)*


2010-11

(n) % Contributory factors for behaviour incidents

Communication problem 59 1.5% Other 57 1.5%

Insufficient or inadequate staff 40 1.0% Failure to follow policy or procedure 31 0.8% Inadequate knowledge or inexperience 30 0.8% Poor teamwork or supervision 24 0.6% Distraction or inattention 12 0.2% Staff did not attend when required 10 0.3% Multiple staff or poor continuity 8 0.2% No PRN medications ordered 7 0.2% Failure to follow advice or instructions 6 0.2% Medication not reviewed 5 0.1% Pressure to proceed 3 0.1% PRN medications not used 4 0.1% Fatigue or stress or unwell 1 0.0% Sub total 297 7.7%

36

Table 5 Number and percent of behaviour incidents by contributory factor (2010-11)*

Patient contributory factors

2010-11

(n) % Contributory factors for behaviour incidents

Mental health related 1559 40.0% Other 552 14.2% Dementia 336 8.6% Pathophysiological factors 332 8.5% Failure to follow advice or instructions 208 5.3% Confusion or disorientation 161 4.1% Alcohol or drug intoxication 130 3.3%

Physical impairments 46 1.2% Language or speech barriers 34 0.9% Affected by medication 22 0.6% Very ill, frail, debilitated or general deterioration

15 0.4%

Cerebral vascular accident 12 0.3% Unsteady on feet 1 0.2% Sub total 3 408 87.6%

System contributory factors (n) (%) Other 99 2.5% Security problem 70 1.8% Environmental hazard or hazardous environment

16 0.4%

Call bell or paging problem 7 0.2% Sub total 192 4.9%

Total 3 897 100.0% * An incident can be associated with more than one contributory factor. Other issues comprise of all other contributory factors grouped together.

37

Figures 21 shows an increasing trend in the number of reported behaviour incidents

associated with alcohol or drug intoxication each year until 2009-10. For 2010-11,

alcohol or drug intoxication accounted for 3.3 % (n=130) of clinical incidents with a

significant decrease observed in the number of incidents reported since 2009-10

(n=565).

Figure 21 Number of behaviour incidents with alcohol or drug intoxication as a contributory factor (2001-11)

3.4.1 Quality improvement strategies to address behaviour incidents


decrease the number of behaviour incidents. Project examples include: *

Establishment of a "Dealing with it" - alcohol and drug harm minimisation patient

health promotion group;

Introduction of a 'WRAP - Wellness Recovery Action Planning' - patient focused

group looking at concepts of recovery, relapse recognition, problem solving, crisis

planning and post crisis planning;

Introduction of an interdisciplinary clinical training model in partnerships with

universities;

Establishment of a rural and remote psychogeriatrician visiting service;

Introduction of training workshops for GPs regarding older adult mental health;

0

100

200

300

400

500

600

Years

Nu

mb

er o

f B

eh

avio

ur In

cid

en

ts w

ith

Alc

oh

ol

an

d D

ru

g In

toxic

ati

on

as a

C

on

trib

uti

ng

Facto

r

Alcohol and Drug Intoxication 90 218 187 281 344 344 424 501 565 130

2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

38

Introduction of one day workshops on depression in the elderly;

Extended closed circuit TV coverage within certain areas to improve the safety

and security of patients, visitors and staff;

Upgrading security and safety within the ward setting;

Improving health outcomes of indigenous Australians through staff education and

training in culturally appropriate risk assessment and care planning;

Audit of the use of the Edinburgh Post Natal Depression Scale (EPDS) in

antenatal clinics; and

Introduction of a committee to oversee the implementation of a mental health

quality action plan.



Continue to implement strategies that address such issues as behaviour

management, alcohol and drug intoxication and physical abuse/aggression; and

Greater focus on behaviour strategies targeting those in the 10-39 year age

group.

39

3.5. Injury incidents

Between 1 July 2010 and 30 June 2011 there were 2 037 injury incidents notified to the

CIMS.

The term „injury‟ in the CIMS process includes any form of clinical incident that physically

harms a patient. Injury incidents can be classified into seven subcategories and include:

pressure ulcers;

other injuries which refers to skin tears, abrasions, bruising, swelling from knocks,

or assaults from other patients;

unintended injury which refers to haematoma formation following intravenous

cannulation, abrasions, tears, bruising from medical equipment such as towel

clips, blood pressure cuffs, and unintended trauma/perforations during surgical

procedures;

result of impact or collision refers to bruises, lacerations from knocking or colliding

with wheelchairs, beds or bedrails;

needle stick or medical sharps injury;

burns; and

injuries of unknown origin.

Between 2002-03 and 2010-11 the injury incident rate has remained within a range of

1.4 to 1.8 incidents per 1 000 bed days. The number and rate of injury incidents has

shown a steady downward trend since 2008-09 (see Figure 22).

40

Figure 22 Number and rate of injury incidents per year (2001-11)*

*Implementation of CIMS was commenced in October 2001, therefore data from 2001-02 is not for a full year.

In 2010-11 the three most commonly notified subcategories of injury incidents were

pressure ulcer (n=581), unintended injury during procedure or treatment (n=472) and

result of impact or collision (n=419). These three subcategories accounted for 72% of all

injury incidents (see Figure 23).

Of these injury subcategories, pressure ulcers have been the most frequently notified

type of injury incident in 2010-11, accounting for 581 (28.5%) incidents of which 3.8%

(n=22) of these were classed as stage 3 pressure ulcers (see Figure 23).

0

500

1000

1500

2000

2500

3000

2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11

Years

Nu

mb

er

of

cli

nic

al

incid

en

ts

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Rate

/1 0

00 b

ed

days

Number of injury incidents

Rate of incidents per 1000 bed days

41

Figure 23 Type of injury incidents 2010-11

The majority of injury incidents (76%; n=1 548) were associated with a moderate level of

harm (Level 5 or 6) to the patient (see Figure 24). Less than 2.5% (n=50) of injury

incidents resulted in an outcome Level of 7, while one incident was given an outcome

Level of 8 which resulted in permanent disability.

42

Figure 24 Injury incidents by outcome level (2010-2011)*

*Missing data n=5

The number and rate of injury incidents increased with age, with the highest injury

number and rate observed for those aged 85 years or older (see Figure 25).

43

Figure 25 Number and rate of injury incidents by age group (2010-11)

Using a multiple response format, the most frequently reported contributory factors

associated with injury incidents were attributed to pathophysiological factors (n=1 071)

followed by physical impairments (n=633; See Table 6).

0

100

200

300

400

500

600

00-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+

Age (years)

Nu

mb

er

of

inju

ry i

ncid

en

ts

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Rate

of

incid

en

ts p

er

1 0

00 b

ed

days

Number of injury incidents Bed rate per 1000 bed days

44

Table 6 Number and percent of injury incidents by type of contributory factor (2010-11)*


2010-11

(n) % Contributory factors for injury incidents

Failure to follow policy or procedure 52 1.7% Inadequate knowledge or inexperience 51 1.7% Other 41 1.3% Communication problem 35 1.1% Distraction or inattention 31 1.0% Poor teamwork or supervision 23 0.7% Insufficient or inadequate staff 16 0.5%

Failure to follow advice or instructions 13 0.4% Pressure to proceed 6 0.2% Misread or did not read documentation 7 0.2% Fatigue or stress or unwell 4 0.1% Sub total 279 8.9%

Patient contributory factors (n) (%) Pathophysiological factors 1071 34.7% Physical impairments 633 20.5% Other 212 6.9% Confusion or disorientation 189 6.1% Very ill, frail, debilitated or general deterioration

128 4.1%

Affected by medication (patient) 127 4.1% Failure to follow advice or instructions 122 3.9% Dementia 112 3.6% Mental health related 59 1.9% CVA or TIA 36 1.1% Language or speech barriers 18 0.5% Wrong or no footwear 11 0.4% Unsteady on feet 9 0.3% Distraction or inattention 6 0.2% Alcohol or drug intoxication 2 0.0% Sub total 2 735 88.3%

System contributory factors (n) (%) Environmental hazard or hazardous environment

47 1.5%

Other 24 0.8% Call bell or paging problem 3 0.1% Security problem 1 0.0% Sub total 75 2.4%

Total 3 089 100.0% *An incident can be associated with more than one contributory factor.

45

3.5.1 Quality Improvement Strategies to address injury incidents


decrease the number of injury incidents: Examples of some of the quality improvement

strategies implemented include: *

The training and education of staff to reinforce knowledge of pressure ulcer

formation and how to avoid such incidents;

Embedding of the SQuIRe Clinical Improvement Pressure Ulcer Programs and

WoundsWest programs which aim to improve wound prevention and management

throughout WA; and

Implementation of Braden Scale audits to measure compliance with pressure

ulcer prevention management.



Continue to implement programs that address pressure ulcer prevention.

46

3.6 Conclusion

WA Health continues to make substantial improvements in preventing and reducing

clinical incidents across the State as evidenced by the rate reduction observed for

medication, falls, “other”, behaviour and injury clinical incidents. This success can be, in

part, attributed to the comprehensive quality improvement projects and programs that

have been implemented by both State and Area Health Services and the significant

efforts of Safety and Quality staff and their clinical colleagues in achieving these

improvements are to be acknowledged and applauded.

Further improvements in clinical incident management have also included the release of

the new Clinical Incident Management (CIM) Policy in September 2011. This new CIM

policy introduced to WA Health both an integrated CIM policy as well as the severity

assessment codes (SAC). The SAC are three codes (1, 2 or 3) used to determine the

appropriate level of analysis, action and escalation to assess the consequences

associated with a clinical incident.

SAC 1 includes all clinical incidents/near misses where serious harm or death is/could be


In WA, SAC 1 also includes the eight nationally endorsed sentinel event categories.

SAC 2 includes all clinical incidents/near misses where moderate harm is/could be


SAC 3 includes all clinical incidents/near misses where minimal or no harm is/could be


The implementation of SAC codes will also assist in the refinement of future CIM reports

by allowing clinical incident data to also be presented by the severity of harm sustained

by the patient. This report also identifies areas within CIM that would benefit from

greater targeting of quality improvement activities, these include:


Analgesics particularly paracetamol, insulin preparations and anticoagulants;


aged 0-14 years, in order to develop targeted prevention strategies;

47

Developing falls strategies specifically targeting those aged 85 years or more;

Strategies to reduce falls incidents resulting in fractures;

Enhancing behaviour strategies targeting those in the 10-39 year age group;

Continue to implement strategies to address issues such as behaviour

management, alcohol and drug intoxication and physical abuse/aggression.

Strategies to reduce “No, wrong or delayed” procedure incidents;

Enhancing communication in health care delivery; and

Continuing to implement programs that address pressure ulcer prevention.

48

4.0 Appendix A: CIMS outcome levels

Outcome Level Description/Example

Potential Incident

Level 1 Dangerous state/potential for harm e.g. understaffed ICU, torn floor

covering.

Level 2

Intercepted prior to causing harm e.g. wrong medication drawn up

but not given, medication allergy identified so medication not given,

bed rails not in place.

Actual Incident

Level 3

No harm occurred. No change in condition or treatment e.g.

harmless medication given to wrong patient.

Level 4

Minor harm occurred not requiring treatment. Reviewed by doctor,

extra observations or monitoring, minor harm.

Level 5

Moderate harm occurred. Minor diagnostic investigations

undertaken (e.g. blood test, x-ray and urinalysis), minor treatment

(e.g. dressings, cold pack and analgesia), security or emergency

services attendance, allied health review.

Level 6

Moderate harm occurred. Diagnostic investigations (e.g. MRI, CT,

surgical intervention), cancellation or postponement of treatment,

transfer to another area not requiring increased length of stay,

treatment with another medication.

Level 7

Significant harm occurred. Increased length of stay, hospital

admission, readmission, transfer to ICU, CPR/resuscitation, secure

ward management, seclusion, fractured neck of femur, morbidity

which continued at discharge.

Level 8 Severe harm occurred. Permanent disability or death.

49

Appendix B: Caveats

The following are noted limitations of incident data collected in the CIMS database:

1. The CIMS is a voluntary reporting system and as such WA Health cannot assume that

the data presented in this report is representative of all clinical incidents.

2. There are occasions when several incidents are notified for the same patient and

same incident. For example, a medication omission that occurs several times to a patient

before being rectified may result in several separate incidents being notified to CIMS.

This can act to artificially inflate the number of incidents. However, there are a number of

safety mechanisms in the CIMS process to minimise or avoid duplicate records from

entering the system.

3. Percentages may not always add up to 100% due to rounding error.

50

Patient Safety Directorate

Performance Activity and Quality Division

Department of Health Western Australia

189 Royal Street, EAST PERTH Western Australia 6004

Tel: (08) 9222 0294

Email: [email protected]

Web: http://www.safetyandquality.health.wa.gov.au/home/

mailto:[email protected]

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learning from clinical incidents: a snapshot of patient...

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