Practice X has designated person Y with primary responsibility for clinical risk management including following up on incidents, injuries, adverse patient events and near misses.
It is a legal requirement under the Occupational Health and Safety legislation, and for insurance purposes, to report any injury sustained, or believed to have been sustained, in the workplace, recognising that good reporting also leads to effective prevention.
Practice X encourages reporting and appropriate management of significant events. Analysis of significant events is also encouraged in order to develop and improve risk management strategies for minimising risks to personal and/or patient safety.
Regardless of whether harm has occurred, the significant events that should be reported include:
- non-clinical events
- slip, fall or other injury
- theft, assault, gas leak, bomb hoax, security breach
- clinical events
- needlestick injury or mucous membrane exposure to blood or bodily fluids
- drug or vaccine incident (eg loss, misplacement or other)
- adverse patient outcome
- failure to complete or inadequate completion of the handover or identification of a patient at the point of transfer of care
- delayed treatment, delayed or failed follow-up, or an unnecessary repeat of tests
- medication errors
- any deviations from standard clinical practice, or where a near miss has occurred
- patient complaints.
Significant events may involve:
- staff (either employed directly by this practice or contractors)
- non-staff (eg patients, visitors).
Actual and potential risks are identified and actions are taken to increase the safety and improve quality of care. The privacy of individuals involved is maintained.
The ‘Significant event reporting and analysis form’ is used to report any significant events. The practice’s MDO is contacted for events that might give rise to a claim.
The ‘Significant event reporting and analysis form’ is:
- completed as soon as possible after an incident has occurred, preferably within 24 hours
- filed in the ‘significant event register’ folder.
Any additional documentation (eg medical or other certificates, reports, pathology results related to the accident/incident) is dealt with as soon as possible and copies of original documents are appended to the ‘Significant event reporting and analysis form’.
For injury occurring in the practice or course of work, WorkCover reporting protocols must also be followed. It is a legal requirement to report all injuries sustained in the workplace.
In situations of potential conflict of interest, for example, a staff WorkCover claim being managed by a GP who is also the employer, it is preferable for that claim to be managed by a doctor outside of that practice.
The designated risk assessment officer conducts a thorough review of the significant event with a view to identifying appropriate corrective measures for future implementation.
This involves identifying and implementing all practicable strategies to reduce or eliminate any potentiating factors, therefore minimising the occurrence of similar incidents, including:
- informing relevant staff (eg at staff meetings, through bulletins) about systems changes and why they have been implemented
- conducting subsequent review/s to ascertain whether the changes that were implemented were successful
- conducting three-monthly reviews of all events involving medical practitioners, nursing and clerical staff
- conducting regular meetings for all doctors so that learning from these events can occur in a non-judgemental way
- conducting regular meetings for all nursing and clerical staff so that learning from these events can occur in a non-judgemental way
- incorporating this process into general practice registrar training (both individually and in group tutorials).
Retain documentation of the investigation process and any agreed actions implemented to minimise the re-occurrence of the incident and to log trends.
Significant event reporting and analysis form
Source: RACGP Standards for general practices
, 5th edition. Criterion QI3.1 – Managing clinical risks, Criterion C5.3 – Clinical handover, Criterion C6.1 – Patient identification.