Data Request Form

SECTION 1: REQUESTOR DETAILS

Name Position

Attachment A
Contact Number Work Location Date Contact Number Work Location

TO BE COMPLETED BY THE PERSON EXTRACTING DATA Email Contact

Request Number Recipient Name (if not the same as
the requestor)

Description Position of Data Request Email Contact Data Supplier Name Urgency (Please circle. Please allow
sufficient approval process time)

Number11-30 Working Days Urgent: 1-10 Working days Contact Semi-Urgent: E-mail Contact

Non-Urgent: 31 + Working Days

Position Information/Data Collection(s) Reason/Purpose (what the Reporting Definition or for) information/data is required data extract criteria used (e.g., inclusions Description of Information/Data and exclusions supply Required (Please include data location or attach ) items/variables required using the Data
Field Guides)

Data Collection(s) from which the data was extracted from Reporting Period Required Reporting Period (e.g., Details as to how the data will be one quarter, one year) used List all persons who will have access to the data Known data quality issues Data Retention Period Frequency (Circle as appropriate) Definition of variables provided (specify or attach) Requestor Signature Date that the data Request Number extract was produced One off Request Fortnightly Monthly 6 Monthly Annually Date Time taken to produce output Completion Date Approved Date Approved Date Not approved Not approved Date Required Ongoing Other (please specify)

SECTION 2: APPROVAL DETAILS

Date Received

Comments (Discussion with requestor revisions Signature

required? Agreement to proceed? Can data be provided?)

Data Custodian Recommendation Data Custodian Signature Other Comments Approval Status* (To be completed
by Data Steward)

Data Steward Signature

SECTION 3: COMPLETION DETAILS

Date Completed Revisions Required Feedback/Comments Please scan and email this form to Data Custodian, Director, Patient Safety Surveillance Unit, Performance Directorate. For any data request queries please call 9222 0294. Data Steward approval is required for any data extraction request or request from non WA Health person. Date Provided

Data Request Pro-Form

Attachment B

Data Release Contract

Attachment C

The following contract is designed to protect the confidentiality and integrity of health information and patient data after its release upon request to an internal (WA Health) or external individual, department or organisation. OBLIGATIONS OF THE REQUESTOR By signing the contract, the requestor: Agrees to maintain the data in a confidential and secure manner in the location to which it was originally released; Acknowledges that the data released remains the property of WA Health; Agrees to, under no circumstances, pass on or divulge the released data to a third party without the prior approval of the Data Custodian; Agrees not to use the data for any purpose other than that for which it was originally requested; Agrees that the source of the data will be properly referenced whenever it is used in publications; Agrees not to copy or store parts or the whole of the released dataset in a directory that may be accessible to anyone else; Agrees not to leave printouts of datasets in any form in an area accessible to anyone else; and Agrees to destroy all copies of the data and hard copies upon completion of its use for the purpose intended and inform the Data Custodian of the outcome.

DISCLAIMER All information/data provided is accurate and up to date at the time of release. WA Health cannot be held liable for the accuracy of the reports based on the analysis of the data. CONTRACT I _____________________________________________________________ (please print)

Of __________________________________________________ department/organisation Acknowledge that I have read and agree to the above provisions of the contract and indicate the intended use of the information requested as follows:_________________________________________________________________________________ I agree to retain the data in the following location in a secure manner:_________________________________________________________________________________ Signed: _______________________________________ Position/Title: __________________________________ Date: _____________________________ Witnessed by __________________________ Position: ____________________________________ Signature: ____________________________ Date:

________________________________ 3

Request Number: _____________________ Received by: ____________________________________

Appendix 1
Area - Data

CIMS Data Fields Guide (AIMS 2.4)

Field Patient Visitor Description Identifies subject of the incident.
#

Extract Field Name Not available from extracts

Tick

Subject of the Incident

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Therapeutic Not available from device, equipment extracts or property# Age of Subject Automatically calculated from Age Group date of birth & date of incident, once both fields have been entered Extensive drop down list with Not available from 65 population groups / extracts countries listed. Known as 'Country of Birth' on the Clinical Incident Management Form Male Female Not stated Unknown Mental Health Status Not applicable Unknown Detained Voluntary Reporter Details Classification Nurse / Midwife* Doctor* Patient Visitor Allied Health* Other (includes free text field) *Drop down lists available to identify designation / level for each discipline (eg. Nurse / Midwife - may be specified as Registered Nurse, Staff Development Nurse, Nurse Manager etc) Legal status of patients in a mental health facility Subject's gender Gender Gender Gender Gender MH_Legal Status MH_Legal Status MH_Legal Status MH_Legal Status Nurse classification Doctor classification Patient Visitor Allied classification Other classification

Population Group

Sex of Subject

Area - Data Subject of the Incident

Field Patient Visitor

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Place of incident

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Ward / unit / place Free text fields Not available from extracts Specific location Date of Incident Not available from extracts Mandatory field, case cannot Date/Time be completed without 'Date of Incident' Free text field, displayed as am or pm Free text field describing patient's diagnosis/condition Incident Time Not available from extracts

Time of Incident Relevant current diagnosis or problems Medical Specialty

Extensive drop down list Medical Speciality available. Known as 'Treating Specialty' on the Clinical Incident Form Yes No N/A Note: A User Defined Field (UDF) is used to identify whether the Open Disclosure Process has been initiated Next of kin or guardian notified Next of kin or guardian notified Next of kin or guardian notified Medical Practitioner notified Medical Practitioner notified Medical Practitioner notified

Was the next of kin / guardian notified?

Was treating medical practitioner notified?

Yes No N/A

Medical practitioner examination of subject

Assessment of Free text field describing Not available from patient's condition assessment of patient after extracts the incident. Includes follow up treatment and investigation Describe what happened including immediate response Contributing factors Free text field describing the incident Describe what happened

Incident summary

Free text field describing the contributing factors

Not available from extracts

Area - Data Subject of the Incident

Field Patient Visitor Treatment or investigations ordered What factors minimised the outcome? How could the incident have been prevented?

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Free text field listing treatment and investigations Free text field describing factors that minimised the outcome Free text field describing preventative strategies that could have prevented the incident Free text field outlining investigation
#

Extract Field Name Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts

Tick

Senior staff member's comments

Results of evaluation following investigation Yes No N/A

Results of evaluation

Has the incident been documented in the medical record?

Not available from extracts Not available from extracts Not available from extracts Note: A User Defined Field (UDF) is used to identify whether the Open Disclosure Process has been initiated Not available from extracts Not available from extracts Not available from extracts Comment on action

Was the patient informed Yes of the incident? No N/A Department head who completed and 'signed off' that the appropriate steps have been taken

Comment on Free text field describing action taken or corrective actions to prevent needed to prevent recurrence recurrence or comment on resource implications Did the incident result in an increase of costs or length of stay, or consume extra resources? Yes

Free text field describing extra Not available from costs incurred as a result of extracts the incident

Not available from extracts

Area - Data Subject of the Incident

Field Patient Visitor

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Have you relayed this information back to the reporter?

No N/A ADRAC TGA Work related injury body Other (includes free text field)

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Not available from extracts Not available from extracts Adverse Drug Reactions Advisory Committee Therapeutic Goods Administration Not available from extracts Not available from extracts Not available from extracts Not available from extracts Specifies the Ward / Department from the Organisational Tree in AIMS, that is responsible for the follow-up and investigation of the incident Workplace

Have the relevant authorities been notified?

Specify ward or department allocated

Third Party Comments Day of Week Month Financial Year Calendar Year Shift Time

Free text field for third party to 3rd party comment on incident comments Note: This information is calculated from fields within Data Manager, but are not actual data entry fields. Week Day Month Fin Year Cal Year Morning/Afternoon/Evening/Ni Shift Time ght. Note: This information is calculated from fields within Data Manager, but is not an actual data entry field Incident Types Wrong medication Patient received wrong additive or fluid medication. Includes wrong formulation. Wrong frequency Wrong time Incident Type Nature of Incident Type

Medication

Medication given more or less Nature of Incident often than ordered. Type Medication was given at the wrong time of day or night Nature of Incident Type

Area - Data Subject of the Incident

Field Patient Visitor Wrong route

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Medication was administered via a route other than that ordered. The correct medication was given to the wrong patient. Rate of the infusion or device was set incorrectly. Note: Overdose or under dose should also be selected during coding. Incident involved side effects as a result of medication. Medication given without a written or verbal order. Medication was given, but there is no signature to verify administration. Medication bottle, box or fluid was not labelled or was labelled incorrectly. Medication had passed use by date.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type Nature of Incident Type Nature of Incident Type

Tick

Wrong patient Wrong infusion rate

Reaction to medication Given without order Given but not signed for No or incorrect labelling Expired medication

Nature of Incident Type Nature of Incident Type Nature of Incident Type Nature of Incident Type Nature of Incident Type Nature of Incident Type Nature of Incident Type

Damaged product Product was in an unusable state at time of incident. Theft or loss Medication could not be located. Note: If a DDA is involved, DDA discrepancy should also be included.

DDA check not done or discrepancy Omission Under dose Overdose

There is a difference between Nature of Incident the actual DDA count and that Type documented in the register or DDA count was not attended. Ordered medication was not administered. Subject was given less than ordered. Nature of Incident Type Nature of Incident Type

Unintentional overdose; an Nature of Incident excessive amount of a Type medication was given, but not ordered.

Area - Data Subject of the Incident

Field Patient Visitor Self inflicted overdose Problem during therapeutic use

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Patient intentionally self administered an excessive dose of medication. Medication had no or inadequate effect despite being administered as per orders. Incident does not fit into the above categories.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type Nature of Incident Type

Tick

Other (includes free text box) Medication Cause of Incident Incorrect calculation Failure to read or misread New order overlooked

Nature of Incident Type

Medication amount or rate was incorrectly calculated. Existing order was misinterpreted or overlooked.

Medication - cause of incident Medication - cause of incident

Incident occurred because of Medication - cause new medication orders, stat of incident medication orders or changes in medication orders were not noted. Medication given when it was to be withheld either temporarily or permanently. Staff did not follow hospital policy or procedures. Script or order was not completed correctly. Medication order was ambiguous or not fully completed. Medication - cause of incident Medication - cause of incident Medication - cause of incident Medication - cause of incident

Administered when held or ceased Failure to follow policy or procedure Prescription or order error Unclear or incomplete order Dispensing error

Utilised for pharmacy errors; Medication - cause also included filling of unit of incident dose dispensers (eg. Dosette, Webster packs); not utilised for administration errors or for patients that self medicate. Medication not available either within the institution or externally. Medication - cause of incident

Medication not available

Area - Data Subject of the Incident

Field Patient Visitor Patient self medicating Previous known adverse reaction Other (includes free text box)

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Used when the patient is responsible for dispensing own medication. Medication given to the patient despite a known past reaction. Incident does not fit into the above categories.
#

Extract Field Name Not available from extracts Not available from extracts Medication - cause of incident Medication - cause of incident Medication - cause of incident Medication(s) involved

Tick

Medication

Medication(s) involved in incident

Lists medications using Medication(s) generic names only (ie involved 'panadeine' will be coded as paracetamol and codeine phosphate). For incidents involving the wrong medication being given to a patient, only the incorrect drug is listed in this field. Medication Route ordered IV Route Ordered This field captures the Route Ordered 'Routed ordered' when the 'Wrong Route' box has been selected. Note: This field is only used when the incident has been classified as 'Wrong Route'. Route Ordered Route Ordered Route Ordered Route Ordered Route Ordered Route Ordered Route Ordered Route Ordered Route Ordered Route Ordered

SC or IM Topical Epidural Intrathecal Inhalation Rectal Enteric Aural Optic Intranasal

10

Area - Data Subject of the Incident

Field Patient Visitor Sub-lingual Oral Other (includes free text box)

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Route Ordered Route Ordered Route Ordered Route given When the incident has been classified as 'Wrong Route' this field is utilised to indicate which route was actually used. Note: This field is only used when the incident has been classified as 'Wrong Route'. Route given

Medication

Route given IV

SC or IM Topical Epidural Intrathecal Inhalation Rectal Enteric Aural Optic Intranasal Sub-lingual Oral Other (includes free text box) Fall Mechanism of fall From bed or cot Patient fell from a sitting or lying position in or on a bed, trolley, stretcher etc.

Route given Route given Route given Route given Route given Route given Route given Route given Route given Route given Route given Route given Route given Incident Type Nature of Incident Type

11

Area - Data Subject of the Incident

Field Patient Visitor From chair or wheelchair

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Patient fell while sitting on a chair or wheelchair, or attempting to stand from a chair or wheelchair. Patient fell from any equipment intended for direct patient treatment.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type

Tick

From therapeutic equipment From toilet or commode In shower or bathroom Getting to or from toilet On same level

Nature of Incident Type

Patient fell while sitting or Nature of Incident attempting to transfer from the Type toilet or commode. Fall occurred in the shower, bathroom or toilet. Nature of Incident Type

Fall occurred while the patient Nature of Incident was walking to or from toilet Type or commode. Fall did not involve the patient Nature of Incident falling from 'something' and Type was either partially or fully weight bearing. Fall occurred while walking up Nature of Incident or down stairs. Type Nature of Incident Type

On stairs

On wet or slippery Fall occurred on a surface surface that was wet or slippery for some reason. Unknown origin

Patient was found on the floor Nature of Incident and circumstances leading to Type fall cannot be established. This code is usually used when there were no witnesses present. Incident does not fit into the above categories. Nature of Incident Type Not available from extracts Mobility aid was indicated, but Not available from not ordered by doctor or extracts physio at time of incident. Mobility aids were prescribed, Not available from but were not being used by extracts the patient at the time of the fall.

Other (includes free text box) Fall Mobility aid at time of fall Indicated but not ordered Ordered but not used

12

Area - Data Subject of the Incident

Field Patient Visitor Used

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Prescribed mobility aid was being used at the time of the fall, includes wheelchairs, walkers, limb splints etc. Not possible to determine whether a mobility aid was in use at the time.
#

Extract Field Name Not available from extracts Not available from extracts Not available from extracts

Tick

Unknown

Not available from extracts

Not applicable Fall Level of independence Independent

Mobility aids aren't relevant to Not available from the incident. extracts Not available from extracts Patient was able to mobilise without assistance from another individual or use of a walking aid, at the time of the fall. Not available from extracts

Dependent on staff Dependent on aids Dependent on parent or carer Fall Activity at time of fall Transferring

Patient required assistance or Not available from supervision from staff to extracts mobilise. Patient required assistance Not available from from therapeutic equipment to extracts mobilise. Patient required assistance or Not available from supervision from a parent or extracts carer to mobilise. Not available from extracts Patient was involved in the Not available from actual process of moving from extracts one piece of furniture or therapeutic device to another. Patient was mobilising. Patient was involved in the process of standing up. Not available from extracts Not available from extracts

Walking Attempting to stand Playing

Patient was playing at time of Not available from fall, this can include falls from extracts play equipment, falls on the same level, running etc. Patient was in the process of attempting to sit down. Not available from extracts

Attempting to sit

13

Area - Data Subject of the Incident

Field Patient Visitor Not specified Other (includes free text box)

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Patient's activity at the time of fall is unknown or unspecified. Incident does not fit into the above categories.
#

Extract Field Name Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts Not available from extracts

Tick

Fall

If escaping from restraints Not applicable Limb restraints Over cot sides Seat belt Posey Not known Other (includes free text box)

Fall

Risk assessment Not applicable Indicates whether the individual was noted to be at risk prior to the fall occurring.

Not available from extracts Not available from extracts Not available from extracts Incident Type

Yes No Behaviour Incident Types Verbal abuse or aggression Physical abuse, aggression or assault Individual involved in the incident used language that was of an insulting nature. Individual involved in the incident displayed physically aggressive or threatening behaviour.

Nature of Incident Type Nature of Incident Type

14

Area - Data Subject of the Incident

Field Patient Visitor Self discharge

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Patient left the hospital against medical advice, but staff were aware of the occurrence.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type

Tick

Non-compliance

Individual involved in the Nature of Incident incident deliberately failed to Type follow requests or instructions, defied rules or regulations. Nature of Incident Type

Intended self harm The incident involves selfmutilation or inappropriate behaviour, but without stated suicidal intent. Suicidal behaviour Individual involved in the or attempted incident indicated an intent to suicide suicide, lacks value of their life or has attempted or successfully taken his/her own life. Absconding A patient was away from the ward, hospital or unit without permission. Length of time away is irrelevant. Individual involved exhibited unacceptable behaviour (suspicious behaviour; aggressive behaviour, but report does not specify physical or verbal; loitering; placing self on the floor).

Nature of Incident Type

Nature of Incident Type

Inappropriate behaviour

Nature of Incident Type

Inappropriate sexual behaviour

The individual involved in the Nature of Incident incident exhibited Type unacceptable sexually orientated behaviour (eg. sexual contact with another patient, regardless of whether consensual; sexual innuendos; flashing others). Behaviour-related incident is specified, but the categories above do not apply. Nature of Incident Type

Other (includes free text box) Therapeutic Device (Property)*

15

Area - Data Subject of the Incident

Field Patient Visitor

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Note: This field is referred to as 'Property' in the Data Manager Module and 'Therapeutic Device' in Analyser Therapeutic Device (Property)* Incident Types Unavailable

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Lists therapeutic devices Not available from extracts

Incident Type Therapeutic device, equipment or property was not available when required. Nature of Incident Type

Failure to use

Equipment, device or property Nature of Incident should have been used (and Type was available), but not utilised. Equipment, device or property Nature of Incident was not working effectively. Type Equipment, device or property Nature of Incident was damaged or broken. Type Sterilisation process was not performed, was inadequately performed or equipment, device or property was contaminated poststerilisation. Nature of Incident Type

Failure or malfunction or faulty Damaged Not sterile or contaminated

Misuse, inappropriate use or misassemble

Equipment, device or property Nature of Incident was used, but not as indicated Type for its intended purpose; the equipment was misassembled; the incorrect type of equipment was used; or the equipment was not put away in the correct place. Incident resulted from a failure Nature of Incident to properly maintain Type equipment, a problem with the design, limitations of the equipment, or a problem due to a system error. Equipment, device or property Nature of Incident was moved from the original Type site or was inadvertently disconnected.

Infrastructure, maintenance or design problem

Unintended removal, dislodgement or disconnection

16

Area - Data Subject of the Incident

Field Patient Visitor

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type

Tick

Note: This field is referred to as 'Equipment' on the Clinical Incident Form Deliberate Equipment, device or property removal by staff or was intentionally removed. client Theft or loss Other (includes free text box) Injury Incident Types Needle stick or medical sharps Needle stick or a sharp medical object caused injury. Does not include sharp objects used for self harm. Not used for staff injuries.

Equipment, device or property Nature of Incident cannot be found. Type Incident does not fit into the above categories. Nature of Incident Type Incident Type Nature of Incident Type

Burn

Injury was a burn caused by Nature of Incident spillage or hot food or fluid, a Type hot pack or some other hot objects. Note: Does not include burns caused by procedural complications (eg. diathermy). Nature of Incident Type

Result of impact or Injury resulted from a person collision or an object colliding or becoming entangled. Pressure area or sore

Injury involved a reddened Nature of Incident area, or the injury was a Type broken area of skin caused by pressure. Indicates whether pressure Timing of Incident area was present on admission. Note: This is taken from the additional pressure ulcer health incident type (HIT) not from CedOC Subject sustained an injury, but the origin of the injury is unclear. The incident was an unintentional injury caused to a patient during a medical procedure or treatment. Nature of Incident Type Nature of Incident Type

Pressure injuries

Injury of unknown origin Unintended injury during procedure or treatment

17

Area - Data Subject of the Incident

Field Patient Visitor Staff injury

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Not used by WA Health - staff injuries should be referred to OSH. Incident does not fit into the above categories.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type

Tick

Other (includes free text box) Safety & Security Incident Types Contamination, environmental hazard or hazardous environment

Incident Type Contamination, environmental Nature of Incident hazards or hazardous Type environment caused a dangerous state.

Lack of or Actual incident being reported Nature of Incident inappropriate staff is the lack of, or inappropriate Type staff. Note: Not used if the lack of or inappropriateness of staff was the contributing factor to the incident. Patient safety and Safety or security of a patient Nature of Incident security was compromised (eg. sharp Type compromised objects left in the vicinity of a self mutilating patient, assault on a patient, patient allocated to an inappropriate bed). Staff safety or security compromised Staff safety or security was Nature of Incident compromised. Used as a Type secondary incident type when aggressive behaviour is directed towards staff.

Breach of security Security procedure breached Nature of Incident procedures (eg. DDA keys left unattended Type on a desk, ID badges stolen). Possession or use Individual had either Nature of Incident of substance consumed, or had possession Type abuse of banned substances (eg. Illicit drugs, implements used for drug usage). Other (includes free text box) Nutrition Incident Types No meal or feed ordered Staff or patient failed to order meal or feed (eg menu not filled in, TPN not ordered). Incident does not fit into the above categories. Nature of Incident Type Incident Type Nature of Incident Type

18

Area - Data Subject of the Incident

Field Patient Visitor Wrong meal or feed ordered

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Meal or feed was ordered, but it was incorrect or inappropriate (eg. standard diet was ordered when patient was on clear fluids, wrong TPN ordered).
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type

Tick

Meal or feed not delivered Wrong meal or feed delivered Fed when nil by mouth No or wrong meal or feed given Aspiration of feed or fluid

Meal or feed was ordered, but Nature of Incident was not delivered to the Type subject. Meal or feed delivered to the Nature of Incident subject, but was not the same Type as that which was ordered. Patient was given a meal when fasting. Meal or feed wasn't given or was incorrect for the individual. Nature of Incident Type Nature of Incident Type

Incident involved food or fluid Nature of Incident being involuntarily inhaled into Type the airways. Cause may include choking, vomiting, incorrect positioning of patient. Subject required nutritional assistance but staff failed to assist. Nature of Incident Type

Assistance with feeding not provided Contamination of food or fluid

The meal or feed was affected Nature of Incident by an impurity. Includes Type foreign bodies and airborne matter (eg. TPN bag pierced during connection, plastic wrap found in a meal). Food or feed has passed use by date or had expired from the time of opening. Nature of Incident Type

Expired or out of date

Out of hours meal Out of hours meal or feed was Nature of Incident or feed not unavailable (eg. parenteral Type available feeds not being arranged, under-supply of after hours provisions). Difficulties with packaging The incident related to difficulties with packing of food or feed. Nature of Incident Type

19

Area - Data Subject of the Incident

Field Patient Visitor Other (includes free text box)

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Incident does not fit into the above categories.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type Incident Type

Tick

Blood, Gas & Oxygen

Incident Types Problem or reaction when receiving blood Other blood or blood products problem (includes free text box) Excessive or inappropriate oxygen or gas given Other oxygen or gas problem (includes free text box) Incident occurred during a transfusion.

Nature of Incident Type

Incident does not fit the above Nature of Incident categories (eg. incorrect Type labelling, blood not available when required, wrong blood given). Incident occurred during the actual process of administering oxygen / gas. Nature of Incident Type

Incident does not fit the above Nature of Incident categories (eg. Inappropriate Type delivery system, problem with requisition, wastage / storage, no oxygen transferred with patient). Incident Type Paperwork is incomplete or Nature of Incident incorrect (commonly used as Type a secondary incident type with medications). Nature of Incident Type

Documentation

Incident Types Documentation error or omission

Illegible or unclear Incident resulted from an inability to read or fully understand paperwork (commonly used as a secondary incident type with medications). Filed incorrectly Paperwork was filed in the incorrect place.

Nature of Incident Type

Patient ID Patient details are incorrect or Nature of Incident incorrect or absent inadequate. Type Specimen ID Specimen labelling incorrect or absent inadequate, incorrect or omitted. Documentation Paperwork inaccessible or unavailable or lost missing. Nature of Incident Type Nature of Incident Type

20

Area - Data Subject of the Incident

Field Patient Visitor Confidentiality breach No, incomplete or incorrect consent

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Information not intended for public knowledge was disclosed. Consent has not been completed or was incorrectly completed, either by medical staff, patient or both.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type Nature of Incident Type

Tick

Other (includes free text box) Other Incident Types No or delayed admission, inappropriate bed or ward

Incident does not fit the above Nature of Incident categories. Type Incident Type The admission process was not attended to as per protocol or the ward or bed allocated is inappropriate for the patient (eg. Lack of available beds required the patient to wait in the A&E Dept for an extended period; MRSA patient not in a single room, aggressive psychotic patient allocated a medical unit bed). Nature of Incident Type

No, wrong or No diagnosis was made or the Nature of Incident delayed diagnosis diagnosis was incorrect or Type was unreasonably delayed. No, wrong or delayed procedure, treatment or assessment Examples include delayed Nature of Incident transfer, observations not Type done, incorrect investigations performed, procedure inappropriate or contradicted, premature removal of sutures, drains, IV cannula, patient not specialled 1:1 when ordered. Note: Not used if the incident involved activities of daily living. Medical event occurred that is Nature of Incident not an incident by definition Type (eg. Cardiac / respiratory arrest, fainting whilst sitting in a chair, seizure). Discouraged from use in WA, doesnt fit the definition of a clinical incident.

Medical emergency

21

Area - Data Subject of the Incident

Field Patient Visitor Poor discharge planning

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Incident involved an ineffective discharge process (eg. Patient leaving hospital without proper instructions, adequate human support or supplies, delayed discharge, x-rays or discharge medications not being given to patient prior to leaving). Incident involved an infection acquired in hospital. The incident involved the wrong patient body part or side of the body. Generally used for theatre or radiology related incidents.
#

Extract Field Name Not available from extracts Not available from extracts Nature of Incident Type

Tick

Hospital acquired infection Wrong patient or body part or side

Nature of Incident Type Nature of Incident Type

Other (includes free text box) Contributing Factors Subject or incident factors Confusion or disorientation Dementia Mental health related Physical impairment

Incident does not apply to the Nature of Incident above categories. Type

Subject's confusion or disorientation contributed to the incident. Subject's dementia contributed to the incident.

CFsu Confusion or disorientation CFsu Dementia

Subjects mental health CFsu Mental related disorder contributed to health related the incident. Subjects physical impairment CFsu Physical contributed to the incident (eg. impairment Dependent on mobility aids, hemiparesis) Subjects CVA or TIA contributed to the incident occurring. CFsu CVA or TIA

CVA or TIA

Very ill, fragile or general deterioration Unsteady on feet

Subject was receiving CFsu Very ill, frail, palliative care, has a terminal debilitated or illness, or has general debility. general deterioration Should not be automatically CFsu Unsteady on assumed on the basis that the feet patient had a fall.

22

Area - Data Subject of the Incident

Field Patient Visitor Wrong or no footwear

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Subject was wearing socks, TEDS or inappropriate footwear.
#

Extract Field Name Not available from extracts Not available from extracts CFsu Wrong or no footwear

Tick

Pathophysiological Subject has a medical CFsu factors condition/diagnosis that is not Pathophysiological covered by other contributing factors factors. Failure to follow advice or instructions Affected by medication Alcohol or drug intoxication Language or speech barriers Distraction or inattention Other (includes free text box) Contributing Factors Staff factors Inadequate knowledge or inexperience Failure to follow advice or instructions Staff involved was new to the CFst Inadequate ward or hospital or knowledge or inexperienced in the area they inexperience were working. Verbal or written instructions or advice was not followed. CFst Failure to follow advice or instructions Subject failed to abide with advice or instructions. Subject was under the influence of medications. Subject was intoxicated following the consumption of alcohol or an illicit substance. CFsu Failure to follow advice or instructions CFsu Affected by medication CFsu Alcohol or drug intoxication

Subject's communication was CFsu Language or affected due to nationality or speech barriers pathophysiological factors. Subject was not paying attention at the time of the incident. CFsu Distraction or inattention

Contributing factor does not fit CFsu Other the above categories.

Misread or did not Staff failed to read or CFst Misread or read misinterpreted documentation. did not read documentation documentation Pressure to proceed Staff were forced to perform in CFst Pressure to undesirable circumstances proceed due to the unavailability or resources, time or system based factors.

23

Area - Data Subject of the Incident

Field Patient Visitor Insufficient or inadequate staff

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Staffing levels were inadequate or the staff themselves were inadequately trained for the duties required. A staff member failed to comply with set protocols or standards. A staff member was requested to attend to a patient or area, but failed to respond to the request.
#

Extract Field Name Not available from extracts Not available from extracts CFst Insufficient or inadequate staff

Tick

Failure to follow policy or procedure Staff did not attend when required Communication problem Poor teamwork or supervision Multiple staff or poor continuity

CFst Failure to follow policy or procedure CFst Staff did not attend when required

Communication problem CFst between staff or between staff Communication and a patient. problem Poor teamwork or supervisions of other staff / patients. CFst Poor teamwork or supervision

More than one staff member CFst Multiple staff is responsible for the delivery or poor continuity of care for the patient (eg. Team nursing during shift; two doctors treating a patient resulting in conflicting treatment). Medication has not been reassessed when required. Medications were indicated and required, but were not ordered. PRN medications were ordered, but were not used when indicated. Staff were 'not paying attention' or were performing other duties at the time of the occurrence. Staff were experiencing fatigue, stress or went home sick. CFst Medication not reviewed CFst No PRN medications ordered CFst PRN medication not used CFst Distraction or inattention

Medication not reviewed No PRN medications ordered PRN medication not used Distraction or inattention

Fatigue or stress or unwell Other (includes free text box) Contributing Factors System factors

CFst Fatigue or stress or unwell

Contributing factor does not fit CFst Other into the above categories.

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Area - Data Subject of the Incident

Field Patient Visitor Security problem

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Security problem contributed to the incident
#

Extract Field Name Not available from extracts Not available from extracts CFsy Security problem CFsy Call bell or paging problem CFsy Environmental hazard or hazardous environment

Tick

Call bell or paging Call bell or paging problem problem contributed to the incident. Environmental hazard or hazardous environment Other (includes free text box) Incident Outcomes Action taken or required Patient notified or educated Patient was notified of incident or was counselled, spoken to, orientated, debriefed or reminded. Factor or exposure that may adversely affect health.

Contributing factor does not fit CFsy Other the above categories.

A_Patient

Relative notified or The subject's relative was educated informed, debriefed or counselled; includes next of kin being informed or educated or follow up calls. MO or consultant or home team notified Restraint team called Police or security called

A_Relative

Doctor notified of the incident. A_Dr

Restraint team was required; includes security being called to restrain individuals Police or security were required or were notified of the incident; does not include security being contacted as part of a restraint team capacity.

A_Restraint

A_Police

Transferred to Individual required transfer another service or (eg to another hospital, ward, area ICU, A&E, Seclusion, secure ward management, another hospital or ward). Staff educated Staff have been spoken to, counselled, debriefed or informed

A_Transfer

A_Staff

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Area - Data Subject of the Incident

Field Patient Visitor Change in treatment

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Care needs or treatment A_Tx changed as a result of the incident.

Equipment and Equipment was withdrawn A_Equip property managed from use, investigated or actions taken to manage the problem; does not include food products or medications. Relevant person notified Relevant third party was notified of the incident or patient was referred (eg. Allied health) A_Relevant

Policy or protocol Policy or protocol reviewed to A_Policy development (or identify effectiveness and review or revision) adequacy. Other (includes free text box) Incident Outcomes Result of incident No injury Actions taken do not fit the above categories. Definition No harm has come to the subject as a result of the incident. Cuts, grazes, abrasions etc. R_None A_Other

Abrasion, laceration or skin tear

R_Tear

Bruise, swelling or Bumps, soft tissue swelling, R_Bruise reddened area swelling from infected IV sites, haematoma. Does not include any burn related injury. Burn Reddened areas from burn related incidents, scorching / erythema/blisters from heat, skin loss from heat. Twisted ankles, back pain / injury, pulled muscles. Fracture or dislocation of any bone. Drowsiness, loss of consciousness, concussion. R_Burn

Sprain or strain Fracture or dislocation Altered level of consciousness

R_Strain R_Fact R_Consc

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Area - Data Subject of the Incident

Field Patient Visitor Altered emotional state

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Emotional responses such as R_Emot upset, angry, distressed, anxious, teary, frightened, shaken or shocked. Pain/tenderness/soreness. Formal complaint (written or verbal) was made. R_Pain R_Complaint

Pain Formal complaint Other (includes free text box)

Incident result does not fit into R_Other the above categories. Note 1: If the incident relates to a Hospital Acquired Infection the organism (if stated) should be entered here; Note 2: If the incident resulted in the death of a patient then the word 'Death should be entered here.

Incident Outcomes

Incident Outcome Criterion Unknown

Definition
The outcome is unknown or not reported. Dangerous state / potential for harm (eg. Understaffed ICU, torn floor covering etc).

Incident Outcome

Potential

Level 1

Incident Outcome

Level 2

The incident was intercepted prior to causing harm (eg. Wrong Incident Outcome drug drawn up, but not given).

Actual

Level 3 (no outcome)

The incident occurred, but there was no harm to the patient or no change in condition or treatment. An incident occurred, but there was only minor harm to the individual, not requiring treatment.

Incident Outcome

Level 4 (minor outcome)

Incident Outcome

Level 5 (moderate An incident occurred and outcome) resulted in minor diagnostic investigations, minor treatment, dressings / cold pack, analgesia, security / emergency services called, allied health review etc.

Incident Outcome

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Area - Data Subject of the Incident

Field Patient Visitor

Description Identifies subject of the incident.

#

Extract Field Name Not available from extracts

Tick

Note: This field is referred to Not available from as 'Equipment' on the Clinical extracts Incident Form Level 6 (moderate Incident resulted in diagnostic to significant investigations such as MRI / outcome) CT scan, cancellation or postponement of treatment, transfer to another area not increasing length of stay, treatment with another drug. Incident Outcome Level 7 (significant Incident resulted in hospital outcome) admission, increased length of stay, readmission, transfer to ICU / HDU / secure ward / seclusion etc. Level 8 (severe outcome) Area User Defined Fields (UDFs) Field 01 Form - ATSI

Incident Outcome

Incident resulted in permanent disability or death. Incident Outcome Definition Entered by Data Entry Staff. Aboriginal or Torres Strait Islander (Page 1 of Clinical Incident Form). Entered by Data Entry Staff. Open disclosure process has been initiated (Page 3 of Clinical Incident Form). Extract Field name UDF 01 ATSI Tick

03 Form - Open Disclosure Initiated 06 D Entry Restraint

Not available from extracts

Entered by Data Entry Staff UDF 06 Restraint for cases involving restraint in relevant mental health setting. UDF requested by one of the Mental Health Services. Note: Additional 19 restraint UDF's available. Entered by Data Entry Staff UDF 06 Seclusion for relevant cases involving seclusion in relevant mental health setting. UDF requested by one of the Mental Health Services. Note: Additional 14 seclusion UDF's available. Selected by Classifiers. Incorrect or incomplete handover identified. UDF 10 Clinical Handover Issue

06 D Entry Seclusion

10 Coding Clinical handover Issue

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Area - Data Subject of the Incident

Field Patient Visitor 10 Coding Smoking related issue

Description Identifies subject of the incident. Note: This field is referred to as 'Equipment' on the Clinical Incident Form Selected by Classifiers. Incident related to patient smoking in hospital or grounds.
#

Extract Field Name Not available from extracts Not available from extracts UDF 10 Smoking related issue

Tick

10 Coding - SAC 1 Entered by Data Entry Staff. UDF 10 SAC 1 Includes all clinical incidents/near misses where serious harm or death is/could be specifically caused by health care rather than the patients underlying condition or illness. 10 Coding - SAC 2 Entered by Data Entry Staff. UDF 10 SAC 2 Includes all clinical incidents/near misses where moderate harm is/could be specifically caused by health care rather than the patient's underlying condition or illness.

29

Area User Defined Fields (UDFs)

Field 10 Coding - SAC 3

Definition

Extract Field name

Tick

Entered by Data Entry Staff. UDF 10 SAC 3 Includes all clinical incidents/near misses where minimal or no harm is/could be specifically caused by health care rather than the patient's underlying condition or illness. Selected by Classifiers. UDF 10 Includes inadequate care in Transfer issues preparation for transfer, inadequate care during transfer, inadequate or no escort, transfer issues between wards/lodges/hospitals/regions, policy issues, transfer communication issues, larger hospital refusing to take patient from smaller hospital, delayed transfer of patient on MHA forms. Selected by Classifiers. Ambulance or RFDS or other required mode of transport unavailable / inappropriate mode of transport used. Selected by Classifiers. A medication error occurred which was a direct result of the implementation/design of the National Inpatient Medication Chart (NIMC). Selected by classifiers. UDF 10 Transport issues

10 Coding - Transfer issues

10 Coding - Transport issues

20 General - National Inpatient Medication Chart

UDF 20 National Inpatient Medication Charts

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Appendix 2 SAC 1 Data Fields

SAC 1 Field/Description Event Month Identifies the month that the incident occurred. Financial year Identifies the financial year that the incident occurred. Public or Private Identifies if the incident occurred within the WA Health (public) or non WA Health (private) system. Sentinel Event category Nationally endorsed sentinel event categories. Public Private Data contained within field Month e.g. January Tick Field Required

Financial year e.g. 2011/2012

Procedure involving the wrong patient or body part resulting in death or major permanent loss of function. Suicide of a patient in an inpatient unit (or whilst on leave) Retained instruments or other material after surgery requiring reoperation or further surgical procedure Intravascular gas embolisation resulting in death or neurological damage Haemolytic blood transfusion reaction resulting from ABO incompatibility Medication error resulting in the death of a patient Maternal death or serious morbidity associated with labour or delivery Infant discharged to wrong family or infant abduction

Non sentinel event SAC 1 Categories Non sentinel event SAC 1 incident categories.

Medication error (not resulting in death) Fetal complications Misdiagnosis and subsequent management Complications of resuscitation Complications of anaesthetic management Complications of surgery Complications of an inpatient fall Hospital process issues Infection control breach The unexpected death of a mental health client Absconding of any mental health patient/consumer

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SAC 1 Field/Description

Data contained within field Any other incident resulting in serious harm or death of a patient.

Tick Field Required

WARM

Yes

Identifies if the SAC 1 incident was notified following No investigation via a process of mortality review identified in the WA Review of Mortality Policy Mental Health Identifies if the SAC 1 incident concerns a mental health patient / client. Qualified Privilege Identifies whether the investigation of the SAC 1 incident will occur under the protection of qualified privilege. Contributory Factors Factors identified through the investigation of a SAC 1 incident that may have contributed to the issues, problems or difficulties observed. Yes No

Yes No

Communication Equipment External Factors Health Information Human Resources Inter-Hospital Issues Knowledge Skills Competence Physical Environment Policies, Procedures, Guidelines Safety Mechanisms Transportation Issues Work Environment Other (Patient Factors)

Further description of sentinel event categories, non sentinel event SAC 1 Incident categories, and contributory factors can be found in the Clinical Incident Management Toolkit located on the Office of Safety and Quality in Healthcare Website. (http://www.safetyandquality.health.wa.gov.au/clinical_incid_man/aims.

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 Department of Health 2012

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