Notifying an incident in the NSW Health Incident Information Management System (IIMS) 1. What is my responsibility for notifying an incident?

All staff are responsible for notifying incidents in IIMS. This includes near misses. 2. How do I identify an incident? An incident can be identified by a number of means: Direct observation You saw the incident happen (or almost happen), or you made (or almost made) the error yourself. Indirect observation You heard about the incident or discovered the error later through means such as reports from staff, death audits, medical record audit, surveillance, peer review, morbidity and mortality meetings, external reviews, complaints, satisfaction surveys and other methods for collecting feedback from the patient and/or carer/family. Regardless of how an incident is identified it must be notified in IIMS. 3. What do I write in the patients health care record? All clinically relevant information such as patient assessment as well as the IIMS number must be documented in the patients health care record. The open disclosure process must also be documented in the patients health care record. 4. Do I have to give my name when entering an incident in IIMS? You have the choice of either identifying yourself or remaining anonymous when notifying an incident in IIMS. The exception to this is when notifying a workplace injury you are required to give your name. If you do not identify yourself, it will not be possible for your manager to provide you with any follow up information. 5. Do I have to include an initial SAC score when I notify an incident? This is not a mandatory field in the incident notification screen, however it provides valuable information to your manager if you do complete this field. 6. Will my SAC score be changed on the initial notification form in IIMS? Your manager will review the initial SAC score and information recorded on the notification form and confirm the actual SAC on the management screen. Your manager should provide you with feedback if the actual SAC score is different to your initial SAC score. To assist in this process always record the IIMS number of the incident at the time of notification and ensure you identify yourself at the time of incident notification. The AHS Clinical Governance Unit reviews initial and actual SAC 1 and SAC 2 incidents to assist in determining the appropriate level of investigation. The AHS Chief Executive is responsible for authorising the SAC score assigned to each Reportable Incident Brief (RIB) submitted to the Department of Health. Changes to the SAC score of a RIB submitted to the Department of Health are to be authorised by the Chief Executive. 7. What do I do if I am unhappy that the actual SAC score is different from my initial SAC score? Initially speak to your manager. If you are not satisfied then contact your local patient safety manager. Contact the Area Health Service Clinical Governance Unit if you are not satisfied with the response from your manager or local patient safety manager.