Learning from serious clinical incidents to improve patient care across SMHS

Integral to creating improvements in patient safety is the need to analyse and learn from clinical incidents, especially serious clinical incidents. With increased learning comes an increased opportunity to develop solutions to improve organisational systems and processes. A safer SMHS is a better SMHS for staff and patients alike.

Read more about clinical incident management at SMHS and the Severity Assessment Code (SAC) categories.

SAC1 clinical incidents

All SAC1 clinical incidents require an investigation using robust methodology and facilitation by an appropriately skilled staff member to be undertaken effectively.

In order to ensure that lessons from SAC1 clinical incidents are learned and future incidents are prevented, every investigation must have one or more recommended actions (recommendations) as a key component of the investigations’ outcome. To be effective these recommendations need to address any factors which were identified as contributing to the clinical incident during the investigation.

All recommendations require endorsement by the relevant hospital’s executive and must be specific, measurable, achievable, realistic and completed in a specified timeframe.

As per the WA CIM Policy 2015 (revised in 2018) (external site), it is a mandatory requirement that all confirmed SAC1 clinical incidents are notified to the Department of Health Patient Safety Surveillance Unit (PSSU) within 7 working days of the clinical incident occurring. The subsequent investigation report and agreed recommendations must be submitted to the PSSU within 28 working days of the SAC1 notification.

See how we measure up

The graph below shows the percentages of patient outcomes associated with 108 clinical incidents confirmed as SAC1s across SMHS.

Figure 1: Percentage of patient outcomes associated with SMHS confirmed SAC1 clinical incidents by patient outcome January – December 2018

Graph shows that for January-December 2018 the total percentage of SAC1 clinical incidents associated with ‘Death’ was 17 per cent and 43 per cent for ‘Serious Harm’ for this time period.
What do these figures show?
  • Figure 1 indicates that for January–December 2018 the total percentage of SAC1 clinical incidents associated with ‘Death’ was 17 per cent and 43 per cent for ‘Serious Harm’ – a combined total of 60 per cent of all SAC1 clinical incidents for this time period.  ‘Moderate harm’ at 21 per cent, ‘Minor harm’ 5 per cent and ‘No harm’ 14 per cent account for the remaining outcomes associated with SAC1 clinical incidents with a collective total of 40 per cent.
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South Metropolitan Health Service