Performance

Continuing to deliver safe and high-quality care

Learning from clinical incidents

EMHS is very proud of the significant improvements we continue to make in providing safe and high-quality care for our patients and consumers. This is our number one priority.

It is recognised, however, that in such a complex and challenging industry, sometimes things can go wrong. We are committed to providing an open and transparent environment that includes supporting staff to report incidents in the event that something does not go according to plan.

During 2021-22, there were 141,793 patient admissions to EMHS hospitals. In addition, 213,508 patients were seen in our EDs and another 716,000 patients were seen in an outpatient clinic or setting.

As a testament to our professional and skilled workforce, the overwhelming majority of these interactions occurred without incident. However, for a very small percentage of patients, errors did regrettably occur during their care — and in some cases, these errors resulted in unintended harm.

In the interests of transparency, we are sharing the number of serious clinical incidents that occurred in 2021-22 at our hospitals and health services.

Every incident provides a critical learning opportunity that enables us to put in place strategies to prevent others from being harmed.

During 2021-22, there were 109 clinical incidents reported with a Severity Assessment Code (SAC) rating of 1 (SAC1). A SAC1 incident is a clinical incident that has, or could have, caused serious harm or death, and which is attributed to health care provision (or lack thereof) rather than the patient’s underlying condition or illness.

The number of SAC1 incidents is reflective of a strong culture of reporting. The most reported types of incidents include; infection control, mental health and patient accidents/falls incidents. All SAC1 clinical incidents are subject to a rigorous investigation with the reports being reviewed by members of the EMHS Executive, as well as the EMHS Board Safety and Quality Committee.

Morbidity and mortality (M&M) review is a forum for clinicians to openly and transparently discuss the quality of care provided to patients who have died or experienced significant morbidity while under the care of a health service. The EMHS has continued to mature and strengthen its M&M review processes. M&M review is an essential component of an integrated approach to identifying clinical incidents, opportunities for quality improvement and organisational learning through peer review.

EMHS has implemented a number of other initiatives to reduce the number and severity of SAC1 incidents. 

EMHS established a Reducing Falls with Harm Improvement Group to review and discuss patient falls in health care. EMHS sites shared current strategies in the prevention of harm from falls, including minimisation plans based on best practice and evidence to improve patient outcomes. The review of previous falls SAC1 recommendations was shared across EMHS, enabling sites to learn from past incidents.   

In 2021-22, EMHS introduced paediatric sepsis pathways across sites with paediatric services, resulting in an evidence-based and consistent approach to the identification and management of sepsis in the paediatric setting. Further implementation of inpatient adult sepsis pathways is also occurring.

EMHS participates in healthcare associated infection (HAIs) surveillance programs including the monitoring of hospital acquired blood stream infections (HABSI), enabling review of current practice. EMHS has created an HABSI action plan to reduce HAIs to ensure practice improvement and better patient outcomes. 

EMHS has implemented the Care Coordination in Mental Health Framework project, which revised and implemented a mental health framework of care and pathways to support consumers in a recovery orientated approach. A key aspect of the Care Coordination Framework aims to support consumers from point of entry or re-entry to discharge, to ensure there is a seamless transition from mental health services to the next point of care during this higher-risk period.  

Of the 109 serious incidents reported in 2021-22, the patient outcome¹ was noted as:

¹The outcome does not necessarily arise as a direct cause of the incident. Factors other than healthcare-related may have contributed to the patient’s outcome.