Incident management and open disclosure

An incident management system is the way a healthcare service records and learns from safety and quality incidents, near misses and adverse events. It relies on a culture of reporting and review, so individuals and services can learn from previous adverse events and change their processes and systems to reduce the risk of them happening again. 

The incident management system should include:

• A paper-based or electronic register where incidents can be recorded and tracked 
• Training and support for the workforce to recognise, respond to and report incidents
• Support for patients, carers and families to communicate concerns or report incidents 
• A process for responding to and reviewing incidents that involves relevant members of the workforce and provides timely feedback to the workforce, patients, carers and families who have communicated concerns or incidents 
• A process for regular analysis of incidents recorded to inform safety and quality improvement priorities and risks, and used to monitor and measure the healthcare service’s performance
• A process to regularly review and improve the incident management system. 

An incident register collects data that includes:

• Date of the incident 
• A description of the incident, including timelines, where relevant
• Information on who was involved in the incident (including all workforce, patients, carers, family or visitors to the service such as contractors)
• A description of the harm, if any, the person experienced because of the incident, if known 
• Action taken immediately following the incident to ensure the safety of staff, patients and the community (for example, an ambulance was called or urgent repairs to premises occurred)
• Details of open disclosure that occurred at the time of the incident, where applicable
• A statement about to whom the incident was reported, where applicable
• Name (and contact details, if needed) of the person who reported the incident – this may be a member of the workforce, patients, carers, family or visitors
• Name (and contact details, if needed) of the person who documented the incident.

When reviewing incidents, for safety and quality improvements, healthcare services should consider what changes or additional actions could be introduced to prevent the incident occurring again.

Links to Actions 1.04 Risk management and 1.02 Policies and procedures

• How does your healthcare service identify, report, document and manage incidents?
• How are patients, carers and families supported to communicate concerns or report incidents?
• How could the incident management system be improved?

• Implement an incident management system. 
• Train the workforce to use the incident management system, including types of incidents, risks and near misses that must be reported.
• Inform patients about how they can report risks, incidents or concerns.
• Regularly review incident data, and identify learnings from incidents that could be implemented to drive improvements in safety and quality. 
• Periodically review the incident management system to identify areas of improvement.

For certain healthcare services, it may be appropriate to integrate incident management systems with other systems to meet safety and quality requirements, and legal and business obligations. 

• The type and comprehensiveness of evidence used is dependent on each healthcare service context, but could include: 
• Description of how your service identifies, reports, documents and investigates incidents, near misses and adverse events
• Examples of reports on incidents, near misses and adverse events identified in the service, and the actions taken to manage identified risks
• Training documents (for example, syllabus, attendance records and competency assessments) relating to recognising, reporting, investigating, recording and analysing incidents, near misses and adverse events
• Meetings or communication records where discussion occurred about incidents and the strategies and actions taken to address identified risks
• Information and resources, including incident reporting forms and tools, that are accessible to the workforce and patients
• Records of improvements made from incidents
• Records of risks identified from the analysis of incidents
• Evidence of incident management reviews.

Commission resource

• Incident management guide – provides a concise overview of the incident management process and its underlying principles.

Other resource

• Allied Health Professions Australia: Incident Management (Allied Health National Insurance Disability Scheme [NDIS] Support) – provides resources to support healthcare providers establish incident management systems under the National Disability Insurance Scheme. Can be used as example policies and forms.

Healthcare service providers should use the Australian Open Disclosure Framework whenever patients are harmed during the delivery of health care. ‘Open disclosure’ describes the process of the healthcare provider having an open discussion with the patient, carers and the patient’s family about adverse events that resulted in harm to the patient while receiving health care. Further information on open disclosure, including applicability for sole practitioners and small practices is available on the Commission’s website. 

Elements of open disclosure in the framework are: 

• An apology or expression of regret, which should include the words ‘I am sorry’ or ‘we are sorry’ 
• A factual explanation of what happened 
• An opportunity for the patient who has experienced harm or an unexpected event, and/or their carers and family to relate their experience
• A discussion of the potential consequences of the adverse event
• An explanation of the steps being taken to manage the adverse event and prevent recurrence.

In using the framework, healthcare services should:

• Foster a culture that supports and prioritises open disclosure processes as part of good clinical care
• Determine how open disclosure processes are implemented in the healthcare service, taking into consideration the principles and elements of the framework 
• Support and provide open disclosure training, peer support and mentorship, including communications skills training that supports empathetic and respectful communication 
• Ensure there is access to appropriate support for the workforce, people who have experienced harm and their support people 
• Conduct continuous evaluation of open disclosure processes and feedback of results to the workforce, patients who have experienced harm and their support people for quality improvement 
• Try to communicate lessons learned throughout the broader health system through existing mechanisms and relevant authorities, such as conferences or professional networks.

Links to Actions 1.05 Incident management and 2.07 Accessing healthcare service information

• Who is responsible for taking action when a patient is harmed during care in your service?
• How are the workforce trained and supported to implement open disclosure?

• Adopt and implement the Australian Open Disclosure Framework when a patient is harmed in the delivery of care.
• Ensure that members of the workforce who will be involved in open disclosure are appropriately trained.
• Regularly review incidents, recorded in the incident management system against the healthcare service’s processes and consistency with the Australian Open Disclosure Framework.

• The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of the policies and processes will likely depend on the size of the healthcare service, but could include:
• Policy documents that are consistent with the principles and processes outlined in the Australian Open Disclosure Framework, and which have been adopted and implemented in a way that reflects the context of service provision
• Meeting, communication records or records of an open disclosure 
• Training documents (for example, syllabus, attendance records, competency assessments or role-play scenarios where open disclosure is required) relating to the open disclosure program.

Commission resources

• Australian Open Disclosure Framework – Better communication, a better way to care – the framework is designed to enable healthcare services and healthcare providers to communicate openly when health care does not go to plan. 
• Implementing the Australian Open Disclosure Framework in Small Practices – a resource to assist sole healthcare providers and those working in small practices implement and practice open disclosure in accordance with the Australian Open Disclosure Framework. 
• Preparing and participating in open disclosure discussions – a fact sheet for consumers and carers.
• Open disclosure – what to expect if you experience harm during health care? – a fact sheet for consumers and carers.