Incident Information Management System
Severity Assessment Code
Open Disclosure
Near miss incidents do not require open disclosure
Everyone is commited to provided good care
But sometimes something goes wrong
- it is a discussion with patient and/or family about a patient related incident
- provides an ethical framework to fulfil duty of care
aim is to maintain pt’s feeling that we are on their team
Support staff and maintain everyone’s confidentiality
?Notify MDO/TMF
Timely – as soon as possible after the incident (def within 24h)
Acknowledge incident and its impact (I realise this is causing you distress)
Explain incident - open, honest facts only, don’t hypothesise
Apologise/express regret as a team with empathy
Reassurance – we will treat with this, investigate why and take action to prevent
Investigate – Route-cause analysis for SAC level1
Feedback to the patient and staff (to reassure environment is safe), nominate a time for the next update.
Document – so that others can learn (journal or otherwise)
References:
EDMORE, NSW health OD guideline
(Mandatory health policy – Dir of Clinical Governance in AHS is responsible)
- SAC 1 leads to reportable incident brief to the Minister
- SAC 1-2 = high level – Open Disclosure Team (Department) managed
- SAC 3-4 = general level – Clinician managed, incident and open disclosure recorded in note
Open Disclosure
Near miss incidents do not require open disclosure
Everyone is commited to provided good care
But sometimes something goes wrong
- it is a discussion with patient and/or family about a patient related incident
- provides an ethical framework to fulfil duty of care
aim is to maintain pt’s feeling that we are on their team
Support staff and maintain everyone’s confidentiality
?Notify MDO/TMF
Timely – as soon as possible after the incident (def within 24h)
Acknowledge incident and its impact (I realise this is causing you distress)
Explain incident - open, honest facts only, don’t hypothesise
- Don’t lay blame/attrib liability or indicate that it was avoidable
- Avoid negative words – wrong, mistake, error, incorrect
- Eg this dose was prescribed, this dose was given, we are sorry that it occurred
Apologise/express regret as a team with empathy
- (this is first step, not admission of guilt, is not allowed to be used in court)
- individuals are insured by Medical Defence Organisations
- hospitals are insured by Treasury Managed Funds
Reassurance – we will treat with this, investigate why and take action to prevent
- provide contact with pt liason/sw
- Attempt to resolve locally, if they would like to escalate options are HCCC or AHPRA
Investigate – Route-cause analysis for SAC level1
Feedback to the patient and staff (to reassure environment is safe), nominate a time for the next update.
Document – so that others can learn (journal or otherwise)
References:
EDMORE, NSW health OD guideline
(Mandatory health policy – Dir of Clinical Governance in AHS is responsible)