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Standards for health services in Australian prisons

Criterion 3.1.2 Clinical risk management system

Our health service has a clinical risk management system to enhance the quality and safety of our patient care.


Indicators

A. Our medical and other clinical staff can describe the process for identifying and reporting a near miss or mistake in clinical care (interview).

B. Our medical and other clinical staff can describe an improvement we have made to prevent a near miss or mistake in clinical care from reoccurring (interview).


Explanation

Near misses and mistakes in clinical care that might harm patients occur in all health services. One review of studies about near misses and mistakes suggests that the frequency with which a GP will be involved in an incident in which an error occurred will be between 5 and 80 times per 100 000 consultations.39 The evidence about the frequency of near misses and mistakes varies but the better constructed studies suggest even higher rates of occurrence.

Most health services already manage clinical risk on a daily basis. Many have informal and ad hoc methods of trying to prevent mistakes. Some health professionals talk to other trusted peers or supervisors about ways to manage risk. Some health services have formal processes such as team discussions or structured techniques to analyse the causes of a near miss or mistake and work out how to reduce the likelihood of its recurrence.

The same mistake can have different causes on different occasions. Part of the quality improvement process (see Criterion 3.1.1: Quality improvement activities) is having a consistent clinical risk management system so that the causes of near misses and mistakes are identified and the related processes are improved to reduce the likelihood of them occurring again.

If a health service does not make improvements after identifying a near miss or mistake then patients may be exposed to an increased risk of adverse outcomes and health service staff may be exposed to an increased risk of medicolegal action. For example, if a clinically significant test result is not communicated to the patient or adequately followed up and if the health service knows this has happened yet fails to improve their systems for following up test results, then the service may be exposed to an increased risk of medicolegal action. A similar risk of medicolegal action may apply where an important detail in a previous consultation is not considered by a GP at the patient’s next consultation, resulting in a significant clinical problem being overlooked and the health service knows this has happened yet fails to improve their system for record keeping. This second example may be more likely with the use of certain electronic based record systems that do not show the previous consultation record when a patient’s health record is opened.

The vast majority of incidents do not lead to patient harm. They are deemed ‘near misses’ that are caught before any harm to a patient occurs. For example, a doctor may prescribe a medicine for a patient who then tells the doctor they are allergic to that medicine and so the doctor changes the prescription. Similarly, a doctor may notice that a nurse has prepared an incorrect vaccine for a patient and advises the nurse accordingly, who then replaces it with the correct vaccine. These ‘near misses’ can provide important opportunities for quality improvement within a health service.

The health service needs to have a process in place whereby health service staff know how to notify a near miss or mistake or an unanticipated adverse outcome. A recent study suggests that staff members who are able to hold discussions about difficult subjects such as disrespect, micromanagement, competence and error are likely to be involved with better patient health outcomes, remain longer in their positions, and be more satisfied with their work.40

Health services will have very different systems in place to identify and reduce clinical risk. It is important however, for health services to be able to demonstrate how and why they have made changes within the health service to reduce risk and improve clinical care.

There are a number of parties involved in caring for people who are incarcerated in prisons. Health service staff need to know how to report a concern that the actions of another party (eg. government department or prison management) may compromise the quality or safety of healthcare provided by the health service. It is critical that health services are able to make direct contact with the relevant government department in the event that an administrative, management or other criminal justice process is likely to cause a clinical mistake or pose a risk to patient safety (see Criterion 1.4.2: Clinical autonomy for medical and other clinical staff).

The RACGP recommends that medical and other clinical staff notify their medical defence organisations of all events or circumstances that they perceive might give rise to a claim.

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