20 January 2012

State Spinal Cord Injury Service (SSCIS)

Incident Management Feedback Form

The provision of optimal care and quality improvement across the spinal cord injury (SCI) model of care is a key focus area for the SSCIS. A system wide approach to incident management is one methodology to assist in the improvement of services and consistent with NSW Department of Health policy [1] which notes that a:

“consistent and coordinated approach to the identification, notification, investigation, analysis of incidents with appropriate action on all incidents andallows the lessons learned to be shared across the whole health system”

Many people with SCI receive care in emergency departments, non-specialist inpatient and outpatient services; they may also receive care in the community or in residential facilities. In most cases the location and standard of care is appropriate and of good quality.

Incidents may occur at any time in the care continuum. An incident may be defined as:

“Any unplanned event resulting in, or with the potential to result in death, injury, ill health, damage or other loss which may occur as a result of limited resources, knowledge or skills, or a system with inability to support the needs of a client in a timely fashion”. [2]

In order to establish a systematic approach the SSCIS has established a process to report, review and act on incidents that have a statewide impact or are inconsistent with the SSCIS model of Care. This SSCIS process does not alter local incident reporting policies and aims to be an adjunct to the NSW Health incident reporting process.

During 2012 the SSCIS will focus on the following areas of clinical practice:

  • Delayed referrals, > 24 hours, for new traumatic SCI (regardless of the cause for the delay)
  • Patients transferred from other facilities with grade 3 or 4 pressure ulcers or embolic events
  • Spinal & Plastic surgical issues: to be forwarded only after review at the RNSH & POWH Spinal Surgical or Pressure Care Service Team Meetings
  • Autonomic Dysreflexia that has not been well managed
  • Extended length of stays due to external issues (see appendix 1)
  • Other systemic incidents

During 2012 if incidents occur that are not included in the above list please discuss with your Director/Manager and if determined as appropriate refer them to the SSCIS manager for consideration by the Clinical Development Committee

SSCIS Incident Reporting Pro-forma

SSCIS incident reporting guidelines:

1)Report incidents as per local policy prior to forwarding a report to the SSCIS for consideration

2)Please discuss the incident with your Director or Manager prior to forwarding to the SSCIS

3)Reports are not to contain details that identify the patient

4)Reports may be made for incidents you are aware of that did relate directly to your service. E.g. community / outpatient clients or cases you have consulted on.

5)Professional matters or the performance of an individual are not to be reported

6)Once received the SSCIS will contact you to clarify any facts and then investigate the details of the incident

7)Incident reports and recommended actions will be presented to the SSCIS Clinical Development Committee quarterly, or more frequently if required, for discussion. The SSCIS has explored a series of options with the Clinical Excellence Commission to bring about systematic change including; reporting through the IIMS as a statewide service, review by NSW Ambulance and Trauma Networks, raising incidents and working directly with Local Health District Clinical Governance Units and issuing NSW Health Ministry Safety Alerts.

1) Date of the incident / / 2012

2) Where did the incident occur? ______

3) Describe the issue as you understand it? ______

4) What was the outcome or impact for the patient? ______

______

5) What other contextual factors are important to understand or explore further? ______

6) What could have been done differently from your perspective? ______

______

7) What are some possible recommendations for action by the SSCIS (if resources sufficient)? ______

8) Is this incident being investigated within your service? Yes/ No

9)Who in your service is conducting the investigation?

10) Completed by: Date:

11) Your Email details:

Please FAX completed pages 2 & 3of this form:

TO:Frances Monypenny, ACI SSCIS Network Manager

FAX:02 8644 2198

Thank you.

If you have any questions about the SSCIS Incident Reporting or require guidance on the reporting process please contact:

  • Frances Monypenny ph 0404 010 918
  • or A/Prof J Middleton

Appendix 1

Suggested guide for reporting extended length of stays per neurological group, based on SSCIS data. Report LOS greater than 15% of median LOS

Tetra Complete / Tetra Incomplete / Para Complete / Para Incomplete
Acute MLOS. / 70 / 39 / 46 / 26
Rehabilitation MLOS / 176 / 126 / 136 / 99

Notes:MLOS = Median hospital length of stay. Median figures based on SSCIS data for the years 2004 - 2007 inclusive.

  • January 2010
  • For review by the SSCIS Clinical Development Committee at each quarterly meeting and at 12 months
  • Review date March 2012

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[1] Incident Management Policy PD2007_061

[2] (PD2005_234 Effective Incident Response Framework for Prevention and Management in the Health Workplace.)