AIMS Annual Report2006-2007 2007-08

Delivering Safer Healthcare in Western Australia
Learning from Clinical Incidents: A Snapshot of Patient Safety in Western Australia 2006-2007 & 2007-2008
Acknowledgements The Office of Safety and Quality in Healthcare (OSQH) would like to thank and acknowledge the contribution of all clinical staff who have devoted their time and effort to collecting and reporting clinical incidents. We would also like to acknowledge the patients and their families who have experienced unintended harm whilst receiving care in our health system. By reporting, investigating, implementing change and sharing the lessons learned, we aim to reduce human error and its impact on all those involved in clinical incidents.
This publication has been produced by the Office of Safety and Quality in Healthcare Department of Health, Western Australia, 2010.
All Rights Reserved. No part of this report may be reproduced in any form without written permission of the copyright owners.
Office of Safety and Quality in Healthcare Department of Health PO Box 8172 Perth Business Centre Western Australia 6849
Telephone (08) 9222 4080 Facsimile (08) 9222 2032 Web http://www.safetyandquality.health.wa.gov.au
The data presented was correct as of July 2009.
Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08
Table of Contents
List of Tables.......................................................................................................... 4 List of Figures......................................................................................................... 5 Glossary................................................................................................................. 9 Key Terms Acronyms ........................................................................................ 12 Executive Summary ............................................................................................. 13 1. Introduction ...................................................................................................... 20 2. Methodology..................................................................................................... 22 3. Results ............................................................................................................. 24 3.1 General Overview........................................................................................... 24 3.2 Falls Incidents ................................................................................................ 26 3.2.1 Introduction.................................................................................................. 26 3.2.2 Results ........................................................................................................ 26 Falls Incidents 2006-07 and 2007-08.................................................................... 26 Trends in Falls Incidents in 2001-08 ..................................................................... 26 Outcome of Falls Incidents ................................................................................... 28 Nature and Location of Falls Incidents.................................................................. 32 Patient Demographics .......................................................................................... 33 Contributing Factors ............................................................................................. 36 3.2.3 Discussion ................................................................................................... 37 3.2.4 Key Messages ............................................................................................. 40 3.3 Medication Incidents....................................................................................... 41 3.3.1 Introduction.................................................................................................. 41 3.3.2 Results ........................................................................................................ 42 Medication Incidents 2006-07 and 2007-08 .......................................................... 42 Trends in Medication Incidents 2001-08 ............................................................... 42 Outcome of Medication Incidents ......................................................................... 43 Type of Medication Incident.................................................................................. 44 Omission Incidents ............................................................................................... 46 Overdose Incidents .............................................................................................. 49 Wrong Medication, Additive or Fluid Incidents ...................................................... 52 Medications Involved in Incidents ......................................................................... 57 Patient Demographics .......................................................................................... 59 Contributing Factors ............................................................................................. 60 3.3.3 Discussion ................................................................................................... 62 3.3.4 Key Messages ............................................................................................. 64 3.4 Behaviour Incidents ........................................................................................ 65 3.4.1 Introduction.................................................................................................. 65 3.4.2 Results ........................................................................................................ 65 Behaviour Incidents 2006-07 and 2007-08 ........................................................... 65 Trends in Behaviour Incidents 2001-08 ................................................................ 65 Outcome of Behaviour Incidents........................................................................... 66 Type of Behaviour Incidents ................................................................................. 68 Physical Abuse, Aggression or Assault ................................................................ 69 Verbal Abuse or Aggression ................................................................................. 74 Absconding .......................................................................................................... 78 Behaviour Incidents in WA Mental Health Facilities .............................................. 82 Behaviour Incidents in WA Emergency Care Facilities ......................................... 83 Contributing Factors ............................................................................................. 85 Patient Demographics .......................................................................................... 88 3.4.3 Discussion ................................................................................................... 90 3.4.4 Key Messages ............................................................................................. 92 3.5 Other Incidents ............................................................................................. 92
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3.5.1 Introduction.................................................................................................. 92 3.5.2 Results ........................................................................................................ 93 Other Incidents 2006-07 and 2007-08................................................................. 93 No, Wrong, Delayed Procedure, Treatment or Assessment ................................. 94 Other .................................................................................................................... 97 No or Delayed Admission, Inappropriate Bed or Ward.......................................... 99 Medical Emergency............................................................................................ 101 No, Wrong or Delayed Diagnosis ....................................................................... 103 Poor Discharge Planning.................................................................................... 105 Wrong Patient, Body Part or Side....................................................................... 107 Healthcare Associated Infection ......................................................................... 109 Contributing Factors ........................................................................................... 111 3.5.3 Discussion ................................................................................................. 112 3.5.4 Key Messages ........................................................................................... 114 3.6 Injury Incidents ............................................................................................. 115 3.6.1 Introduction................................................................................................ 115 3.6.2 Results ...................................................................................................... 115 Injury Incidents in 2007-08 ................................................................................. 115 Trends in Injury Incidents in 2001-08.................................................................. 115 Outcome ............................................................................................................ 116 Type of Injury ..................................................................................................... 118 Contributing Factors ........................................................................................... 120 Patient Age......................................................................................................... 121 3.6.3 Discussion ................................................................................................. 123 3.6.4 Key Messages ........................................................................................... 124 Appendix A: Caveats.......................................................................................... 125 Appendix B: AIMS Outcome Levels.................................................................... 126 Reference List .................................................................................................... 127
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List of Tables TABLE 1: NUMBER AND RATE OF FALLS INCIDENTS NOTIFIED PER YEAR (2001-08)......................................................................................................... 24 TABLE 2: NUMBER AND RATE OF MEDICATION INCIDENTS NOTIFIED PER YEAR (2001-08) .............................................................................................. 27 TABLE 3: NUMBER OF FALLS INCIDENTS RESULTING IN A FRACTURE BY FRACTURE TYPE (2006-07 AND 2007-08) .................................................... 32 TABLE 4: NUMBER AND PERCENT OF FALLS INCIDENTS BY TYPE OF PATIENT CONTRIBUTING FACTOR (2006-07 AND 2007-08) ....................................... 37 TABLE 5: NUMBER AND RATE OF MEDICATION INCIDENTS NOTIFIED PER YEAR (2001-08) .............................................................................................. 42 TABLE 6: TOP 10 MEDICATIONS INVOLVED IN OMISSION INCIDENTS IN WA (2006-07 AND 2007-08) .................................................................................. 46 TABLE 7: PERCENT OF OMISSION INCIDENTS BY CAUSES OF OMISSION INCIDENT CATEGORY (2006-07 AND 2007-08) ............................................ 48 TABLE 8: TOP 10 MEDICATIONS INVOLVED IN OVERDOSE INCIDENTS IN WA (2006-07 AND 2007-08) .................................................................................. 49 TABLE 9: PERCENT OF OVERDOSE INCIDENTS BY CAUSES OF OVERDOSE INCIDENT CATEGORY (2006-07 AND 2007-08) ............................................ 52 TABLE 10: TOP 10 MEDICATIONS INVOLVED IN WRONG MEDICATION, ADDITIVE OR FLUID INCIDENTS IN WA (2006-07 AND 2007-08)................. 53 TABLE 11: PERCENT OF WRONG MEDICATION, ADDITIVE OR FLUID INCIDENTS BY CAUSES OF WRONG MEDICATION, ADDITIVE OR FLUID INCIDENT CATEGORY (2006-07 AND 2007-08) ............................................ 55 TABLE 12: TOP 10 MEDICATIONS INVOLVED IN MEDICATION INCIDENTS IN WA (2006-07 AND 2007-08)............................................................................ 57 TABLE 13: TOP 10 MEDICATIONS INVOLVED IN ALL MEDICATION INCIDENTS FOR THE 0-14 AGE GROUP IN WA (2006-07 AND 2007-08) ........................ 58 TABLE 14: NUMBER AND PERCENT OF MEDICATION INCIDENTS BY STAFF CONTRIBUTING FACTOR CATEGORY (2006-07 AND 2007-08) .................. 61 TABLE 15: NUMBER AND RATE OF BEHAVIOUR INCIDENTS NOTIFIED PER YEAR (2001-08) .............................................................................................. 66 TABLE 16: NUMBER AND PERCENT OF OTHER INCIDENTS BY TYPE OF STAFF CONTRIBUTING FACTOR (2006-07 AND 2007-08) ..................................... 111 TABLE 17: NUMBER AND RATE OF INJURY INCIDENTS PER YEAR (2001-08)116
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List of Figures FIGURE 1: TRENDS IN THE TOP FIVE PRINCIPAL INCIDENT TYPES IN AIMS BETWEEN 2001-02 AND 2007-08 .................................................................. 25 FIGURE 2: FALLS INCIDENTS AS A PROPORTION OF ALL NOTIFIED INCIDENTS (2001-08)..................................................................................... 27 FIGURE 3: NUMBER OF FALLS INCIDENTS BY OUTCOME LEVEL AND YEAR (2002-08)......................................................................................................... 28 FIGURE 4A: PERCENT OF FALLS INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07)......................................................................................................... 29 FIGURE 4B: PERCENT OF FALLS INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08)......................................................................................................... 29 FIGURE 5A: NUMBER AND PERCENT OF FALLS INCIDENTS BY TYPE OF ASSOCIATED INJURY (2006-07) ................................................................... 30 FIGURE 5B: NUMBER AND PERCENT OF FALLS INCIDENTS BY TYPE OF ASSOCIATED INJURY (2007-08) ................................................................... 31 FIGURE 6A: NUMBER AND PERCENT OF FALLS INCIDENTS BY CATEGORY OF FALLS (2006-07) ............................................................................................. 32 FIGURE 6B: NUMBER AND PERCENT OF FALLS INCIDENTS BY CATEGORY OF FALLS (2007-08) ............................................................................................. 33 FIGURE 7A: NUMBER AND RATE OF FALLS INCIDENTS BY AGE GROUP (200607) ................................................................................................................... 34 FIGURE 7B: NUMBER AND RATE OF FALLS INCIDENTS BY AGE GROUP (200708) ................................................................................................................... 34 FIGURE 8A: RATE OF FALLS INCIDENTS PER 1,000 BED DAYS BY AGE GROUP AND GENDER (2006-07) ................................................................................ 35 FIGURE 8B: RATE OF FALLS INCIDENTS PER 1,000 BED DAYS BY AGE GROUP AND GENDER (2007-08) ................................................................................ 36 FIGURE 9A: PERCENT OF MEDICATION INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) ................................................................................... 43 FIGURE 9B: PERCENT OF MEDICATION INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) .................................................................................... 44 FIGURE 10A: NUMBER AND PERCENT OF MEDICATION INCIDENT TYPES BY TYPE OF MEDICATION INCIDENT CATEGORY (2006-07) ........................... 45 FIGURE 10B: NUMBER AND PERCENT OF MEDICATION INCIDENT TYPES BY TYPE OF MEDICATION INCIDENT CATEGORY (2007-08) ........................... 45 FIGURE 11A: PERCENT OF OMISSION INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) .................................................................................... 47 FIGURE 11B: PERCENT OF OMISSION INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) .................................................................................... 47 FIGURE 12A: PERCENT OF OVERDOSE INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) .................................................................................... 50 FIGURE 12B: PERCENT OF OVERDOSE INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) .................................................................................... 51
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FIGURE 13A: PERCENT OF WRONG MEDICATION, ADDITIVE OR FLUID INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) ........................... 54 FIGURE 13B: PERCENT OF WRONG MEDICATION, ADDITIVE OR FLUID INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) ........................... 54 FIGURE 14A: MEDICATION INCIDENTS BY TIME OF DAY (2006-07).................. 56 FIGURE 14B: MEDICATION INCIDENTS BY TIME OF DAY (2007-08).................. 56 FIGURE 15A: NUMBER AND RATE OF MEDICATION INCIDENTS BY AGE GROUP (2006-07)........................................................................................... 59 FIGURE 15B: NUMBER AND RATE OF MEDICATION INCIDENTS BY AGE GROUP (2007-08)........................................................................................... 60 FIGURE 16A: PERCENT OF BEHAVIOUR INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) .................................................................................... 67 FIGURE 16B: PERCENT OF BEHAVIOUR INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) .................................................................................... 67 FIGURE 17A: NUMBER OF BEHAVIOUR INCIDENTS BY BEHAVIOUR SUBCATEGORY (2006-07)............................................................................. 68 FIGURE 17B: NUMBER OF BEHAVIOUR INCIDENTS BY BEHAVIOUR SUBCATEGORY (2007-08)............................................................................. 69 FIGURE 18A: PERCENT OF PHYSICAL AGGRESSION, ABUSE OR ASSAULT INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) ........................... 70 FIGURE 18B: PERCENT OF PHYSICAL AGGRESSION, ABUSE OR ASSAULT INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) ........................... 71 FIGURE 19A: NUMBER OF PHYSICAL ABUSE, AGGRESSION OR ASSAULT INCIDENTS BY TIME OF DAY (2006-07)........................................................ 72 FIGURE 19B: NUMBER OF PHYSICAL ABUSE, AGGRESSION OR ASSAULT INCIDENTS BY TIME OF DAY (2007-08)........................................................ 72 FIGURE 20A: NUMBER OF PHYSICAL ABUSE, AGGRESSION OR ASSAULT INCIDENTS BY DAY OF THE WEEK (2006-07).............................................. 73 FIGURE 20B: NUMBER OF PHYSICAL ABUSE, AGGRESSION OR ASSAULT INCIDENTS BY DAY OF THE WEEK (2007-08).............................................. 73 FIGURE 21A: PERCENT OF VERBAL ABUSE OR AGGRESSION INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) ..................................................... 74 FIGURE 21B: PERCENT OF VERBAL ABUSE OR AGGRESSION INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) ..................................................... 75 FIGURE 22A: NUMBER OF VERBAL ABUSE OR AGGRESSION INCIDENTS BY TIME OF DAY (2006-07) ................................................................................. 76 FIGURE 22B: NUMBER OF VERBAL ABUSE OR AGGRESSION INCIDENTS BY TIME OF DAY (2007-08) ................................................................................. 76 FIGURE 23A: NUMBER OF VERBAL ABUSE OR AGGRESSION INCIDENTS BY DAY OF WEEK (2006-07) ............................................................................... 77 FIGURE 23B: NUMBER OF VERBAL ABUSE OR AGGRESSION INCIDENTS BY DAY OF WEEK (2007-08) ............................................................................... 77 FIGURE 24A: PERCENT OF ABSCONDING INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) .................................................................................... 78
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FIGURE 24B: PERCENT OF ABSCONDING INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) .................................................................................... 79 FIGURE 25A: NUMBER OF ABSCONDING INCIDENTS BY TIME OF DAY (200607) ................................................................................................................... 80 FIGURE 25B: NUMBER OF ABSCONDING INCIDENTS BY TIME OF DAY (200708) ................................................................................................................... 80 FIGURE 26A: NUMBER OF ABSCONDING INCIDENTS BY DAY OF WEEK (200607) ................................................................................................................... 81 FIGURE 26B: NUMBER OF ABSCONDING INCIDENTS BY DAY OF WEEK (200708) ................................................................................................................... 81 FIGURE 27A: PERCENT OF BEHAVIOUR INCIDENTS BY BEHAVIOUR INCIDENT TYPE IN WA MENTAL HEALTH FACILITIES (2006-07) ................................. 82 FIGURE 27B: PERCENT OF BEHAVIOUR INCIDENTS BY BEHAVIOUR INCIDENT TYPE IN WA MENTAL HEALTH FACILITIES (2007-08) ................................. 83 FIGURE 28A: PERCENT OF BEHAVIOUR INCIDENTS BY BEHAVIOUR INCIDENT TYPE IN WA EMERGENCY CARE FACILITIES (2006-07) ............................. 84 FIGURE 28B: PERCENT OF BEHAVIOUR INCIDENTS BY BEHAVIOUR INCIDENT TYPE IN WA EMERGENCY CARE FACILITIES (2007-08) ............................. 84 FIGURE 29A: NUMBER AND PERCENT OF BEHAVIOUR INCIDENTS BY TYPE OF PATIENT CONTRIBUTING FACTOR (2006-07)........................................ 85 FIGURE 29B: NUMBER AND PERCENT OF BEHAVIOUR INCIDENTS BY TYPE OF PATIENT CONTRIBUTING FACTOR (2007-08)........................................ 86 FIGURE 30: NUMBER OF BEHAVIOUR INCIDENTS WITH ALCOHOL OR DRUG INTOXICATION AS A CONTRIBUTING FACTOR (2001-08) .......................... 87 FIGURE 31A: NUMBER AND RATE OF BEHAVIOUR INCIDENTS BY AGE GROUP (2006-07)......................................................................................................... 88 FIGURE 31B: NUMBER AND RATE OF BEHAVIOUR INCIDENTS BY AGE GROUP (2007-08)......................................................................................................... 89 FIGURE 32A: PROPORTION OF BEHAVIOUR INCIDENTS BY GENDER (2006-07) ........................................................................................................................ 89 FIGURE 32B: PROPORTION OF BEHAVIOUR INCIDENTS BY GENDER (2007-08) ........................................................................................................................ 90 FIGURE 33A: NUMBER AND PERCENT OF OTHER INCIDENTS BY OTHER INCIDENT TYPE (2006-07)............................................................................. 93 FIGURE 33B: NUMBER AND PERCENT OF OTHER INCIDENTS BY OTHER INCIDENT TYPE (2007-08)............................................................................. 94 FIGURE 34A: NUMBER AND RATE OF NO, WRONG, DELAYED PROCEDURE, TREATMENT OR ASSESSMENT INCIDENTS BY AGE GROUP (2006-07)... 96 FIGURE 34B: NUMBER AND RATE OF NO, WRONG, DELAYED PROCEDURE, TREATMENT OR ASSESSMENT INCIDENTS BY AGE GROUP (2007-08)... 96 FIGURE 35A: NUMBER AND RATE OF OTHER INCIDENTS BY AGE GROUP (2006-07)......................................................................................................... 98 FIGURE 35B: NUMBER AND RATE OF OTHER INCIDENTS BY AGE GROUP (2007-08)......................................................................................................... 98
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FIGURE 36A: NUMBER AND RATE OF NO OR DELAYED ADMISSION, INAPPROPRIATE BED OR WARD INCIDENTS BY AGE GROUP (2006-07)100 FIGURE 36B: NUMBER AND RATE OF NO OR DELAYED ADMISSION, INAPPROPRIATE BED OR WARD INCIDENTS BY AGE GROUP (2007-08)100 FIGURE 37A: NUMBER AND RATE OF MEDICAL EMERGENCY INCIDENTS BY AGE GROUP (2006-07) ................................................................................ 102 FIGURE 37B: NUMBER AND RATE OF MEDICAL EMERGENCY INCIDENTS BY AGE GROUP (2007-08) ................................................................................ 102 FIGURE 38A: NUMBER AND RATE OF NO, WRONG OR DELAYED DIAGNOSIS INCIDENTS BY AGE GROUP (2006-07)....................................................... 104 FIGURE 38B: NUMBER AND RATE OF NO, WRONG OR DELAYED DIAGNOSIS INCIDENTS BY AGE GROUP (2007-08)....................................................... 104 FIGURE 39A: NUMBER AND RATE OF POOR DISCHARGE PLANNING INCIDENTS BY AGE GROUP (2006-07)....................................................... 106 FIGURE 39B: NUMBER AND RATE OF POOR DISCHARGE PLANNING INCIDENTS BY AGE GROUP (2007-08)....................................................... 106 FIGURE 40A: NUMBER AND RATE OF WRONG PATIENT, BODY PART, SIDE INCIDENTS BY AGE GROUP (2006-07)....................................................... 108 FIGURE 40B: NUMBER AND RATE OF WRONG PATIENT, BODY PART, SIDE INCIDENTS BY AGE GROUP (2007-08)....................................................... 108 FIGURE 41A: NUMBER AND RATE OF HEALTHCARE ASSOCIATED INFECTION INCIDENTS BY AGE GROUP (2006-07)....................................................... 110 FIGURE 41B: NUMBER AND RATE OF HEALTHCARE ASSOCIATED INFECTION INCIDENTS BY AGE GROUP (2007-08)....................................................... 110 FIGURE 42A: PERCENT OF INJURY INCIDENTS BY OUTCOME LEVEL CATEGORY (2006-07) .................................................................................. 117 FIGURE 42B: PERCENT OF INJURY INCIDENTS BY OUTCOME LEVEL CATEGORY (2007-08) .................................................................................. 117 FIGURE 43A: NUMBER AND PERCENT OF INJURY INCIDENTS BY TYPE OF INJURY CATEGORY (2006-07) .................................................................... 119 FIGURE 43B: NUMBER AND PERCENT OF INJURY INCIDENTS BY TYPE OF INJURY CATEGORY (2007-08) .................................................................... 119 FIGURE 44A: NUMBER AND PERCENT OF INJURY INCIDENTS BY TYPE OF PATIENT CONTRIBUTING FACTOR (2006-07)............................................ 120 FIGURE 44B: NUMBER AND PERCENT OF INJURY INCIDENTS BY TYPE OF PATIENT CONTRIBUTING FACTOR ........................................................... 121 FIGURE 45A: NUMBER AND RATE (PER 1,000 BED DAYS) INJURY INCIDENTS BY AGE GROUP (2006-07)........................................................................... 122 FIGURE 45B: NUMBER AND RATE (PER 1,000 BED DAYS) INJURY INCIDENTS BY AGE GROUP (2007-08)........................................................................... 122
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Glossary
Advanced Incident Management System (AIMS) a system developed by Patient Safety International (now iSoft) for collecting and analysing information on clinical incidents. It includes voluntary reporting, investigating, analysing and monitoring of clinical incidents.
Bed days the number of days a patient stays in hospital between admission and discharge. An aggregate measure of health service utilisation.
Clinical incident an event or circumstance resulting from healthcare which could have, or did lead to unintended harm to a person, loss or damage, and / or a complaint. In the context of this report a person includes a patient, client or visitor.
Clinical incident management the process by which clinical incidents are notified, investigated, analysed and recommendations monitored for the purpose of improving patient safety and quality of healthcare.
Co-morbidities the presence of one or more disorders (or diseases) in addition to a primary disorder or disease.
Contributing Factor a factor that contributes to the occurrence of an incident.
Harm includes death, disease, injury, suffering and / or disability.
Healthcare Associated Infection potentially preventable infections associated with hospitalisation.
Increased length of stay a situation whereby a patient has to stay longer in hospital than would normally be expected.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Injury in the context of AIMS includes burns, injury due to an impact or collision, pressure ulcers, injury of unknown origin, unintended injury during procedure or treatment, or other injuries not classifiable in the previous categories.
Minor outcome an incident associated with minor harm to a patient not requiring treatment but perhaps extra observations or monitoring. Refers to Outcome Level 4 in AIMS.
Moderate outcome an incident associated with a moderate level of harm to the patient requiring review by a doctor and minor diagnostic investigations or treatment (e.g. x-ray, blood tests, analgesia, and minor dressings). Refers to Outcome Level 5 to 6 in AIMS.
Near miss clinical incidents that may have been but were not associated with harm to the patient.
Outcome end result or consequence of an incident to the patient.
Outcome Level one of eight levels of consequence assigned to clinical incidents in AIMS, primarily denoting severity of the incident to the patient, client or visitor (see Appendix B).
Overdose too large a dose of medication.
Pathophysiological factors factors associated with disease.
Principal Incident Type (PIT) the category into which a clinical incident reported to AIMS is classified. There are nine PIT categories. If an incident does not fit into one of the nine categories it is classified as other.
Root Cause Analysis (RCA) a systematic investigative technique aimed at identifying root causes / contributing factors of problems, events or incidents.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Safety and Quality Investment for Reform (SQuIRe) The Safety and Quality Investment for Reform (SQuIRe) Program was established in July 2006 to strengthen the WA Department of Healths clinical governance and patient safety management systems, and to ensure the delivery of safe, high quality, evidence-based healthcare to patients and the WA community.
Sentinel event notified rare events that lead to catastrophic patient outcomes.
Severe outcome an incident associated with severe or catastrophic harm to a patient (permanent disability or death). Refers to Outcome Level 8 in AIMS.
Significant outcome an incident associated with a significant level of harm to a patient. Refers to an Outcome Level of 7 in AIMS. Examples include an incident resulting in an increased length of stay in hospital, admission to hospital, readmission to hospital, transfer to ICU, CPR/resuscitation, secure ward management, seclusion, fractured neck of femur, morbidity which continued at discharge. SQuIRe Clinical Practice Improvement (CPI) Program - The SQuIRe Clinical Practice Improvement (CPI) Program supports the implementation of practices that improve patient outcomes. There are eight CPI initiatives grouped in three clusters. Cluster 1 - evidence based clinical practice, Cluster 2 - medication reconciliation, and Cluster 3, infection control practices.
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Key Terms Acronyms

ACSQHC AHS AIMS BIPAP CPI HISWA IV MET MRI PIT PRN SQuIRe UK USA WA WAASM WARM Australian Commission on Safety and Quality in Health Care Area Health Service Advanced Incident Management System Bi-level Positive Airway Pressure Clinical Practice Improvement Healthcare Infection Surveillance Western Australia Intravenous Medical Emergency Team Magnetic Resonance Imaging Principal Incident Type Pro Re Nata (as needed) Safety and Quality Investment for Reform United Kingdom United States of America Western Australia Western Australian Audit of Surgical Mortality Western Australian Review of Mortality
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Executive Summary
This combined report documents the key features and trends of the top five clinical incident types notified to the Advanced Incident Management System (AIMS) in Western Australia between July 1 2006 and June 30 2008. AIMS is a voluntary clinical incident reporting system that has been in place in metropolitan and country WA public health services since October 2001 and is just one of several systems used by WA Health to capture and manage clinical incidents and adverse events. The process of clinical incident management enables changes to be implemented at the clinical service delivery level to prevent future incidents from occurring and to improve patient safety.
Clinical Incident Trends 2001-02 to 2007-08 At the time of data analysis there were 189,075 incidents contained in the AIMS database.
Since 2001-02 Falls and Medication incidents have consistently been the PIT categories with the highest number of reported incidents while Behaviour, Injury and Other incidents (incidents that cannot be classified into one of the other nine incident types) have consistently ranked between the 3rd and 5th most reported incidents to the AIMS database.
Between 2002-03 and 2007-08 there was, on average, 6,856 (range 6,823 to 7,856) falls and 5,351 (range 5,202 to 6,693) medication incidents reported per year.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Clinical Incidents 2006-07 and 2007-08 Snapshots A total of 23,586 incidents were entered and classified in AIMS during the 2006-07 financial year compared with a total of 27,322 incidents entered and classified during the 2007-08 financial year.
The number of incidents and the relative proportion of each of the nine PITs and the Other incident type categories are shown in Table 1 (Section 3.1).
Falls and Medication incidents made up more than half (51% 2006-07 and 48.5% 2007-08) of all incidents reported to AIMS for this time period with Other, Behaviour and Injury incidents accounting for a further 36% of all reported events for both financial years.
Falls Falls were the most frequently reported clinical incident in 2006-07 with 6,409 events and in 2007-08 with 6,823 events added to AIMS. In 2006-07, there were 4.3 falls reported per 1,000 bed days compared with 4.4 falls per 1,000 bed days in 2007-08. Based on the Victorian estimate of $4,850 per fall in hospital 1 the total estimated cost to WA Health of falls notified to AIMS in 2006-07 was in excess of $31 million and in 2007-08 in excess of $33 million. The rate of falls increased with age, over 10 falls per 1,000 bed days in the 85 year and older age groups for 2006-07 compared with 9.7 falls per 1,000 bed days in the 85 year and older age group for 2007-08. The majority of falls (80.4% 2006-07 and 83.4% 2007-08) required the patient to be reviewed by a doctor with extra observations and monitoring and / or diagnostic investigations ordered (e.g. x-ray, MRI), while 2.0% of falls led to an increased length of stay in hospital, permanent disability or death. There were four patient deaths in 200607 and seven patient deaths associated with falls in 2007-08. The Falls category with the greatest number of incidents (over one quarter of all falls) included those falls that occurred while the patient was standing or walking.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 In 2006-07 19 falls resulted in fractures with 13 of these being fractured necks of femur (NOF). The median age for patients suffering a fractured NOF as a result of a fall was 84 years. In 2007-08 90 falls resulted in fractures with 37 of these being fractured hips. The median age for patients suffering a fractured hip as a result of a fall was 83 years. Patient co-morbidities, such as poor health, dementia, confusion and frailty, were a contributing factor in almost half of all reported falls. Strategies have been implemented to decrease the number of patients falling including the active participation of health services in the SQuIRe Falls Clinical Practice Improvement (CPI) initiative and the Falls Prevention Network. Specific evidence-based strategies include the development of Falls Risk Assessment Tools, increasing the supervision of patients at risk of falling and nursing at-risk patients in lower beds.
Medication Medication incidents were the second most frequently reported clinical incident in 2006-07 and 2007-08 with 5,570 events and 6,416 events added to AIMS respectively. For 2006-07 there were 3.7 Medication incidents per 1,000 bed days compared with 4.1 Medication incidents per 1,000 bed days in 2007-08. Patients aged less than 15 years had the highest rate of medication incidents with the 5 to 9 year age group having a peak rate of 6.3 incidents per 1,000 bed days. Over half of all Medication incidents were associated with no harm to the patient, while 1.0% of Medication incidents in both 2006-07 and 2007-08 led to an increased length of stay in hospital, permanent disability or death. There were three patient deaths in 2006-07 and four patient deaths associated with Medication incidents in 2007-08. In 2006-07 the top three medications involved in Medication incidents were Paracetamol, Morphine and Oxycodone hydrochloride compared with Paracetamol, Heparin and Insulin in 2007-08.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Missed doses (omissions) were associated with almost one-third of all Medication incidents. In almost half of all Medication incidents a contributing factor related to issues around policies and procedures. Strategies have been implemented to decrease the number of Medication incidents. They include staff training on the recognition of error-prone situations, potential complications, contraindications and drug interactions.
Behaviour Behaviour incidents were the fourth most frequently reported clinical incident type in 2006-07 with 2,884 events captured in the system and the third most frequently reported clinical incident type in 2007-08 with 3,844 events captured. This represented 1.9 Behaviour incidents per 1,000 bed days in 2006-07 and 2.5 Behaviour incidents per 1,000 bed days for 2007-08. The majority of Behaviour incidents (71.0% 2006-07 and 67.7% 200708) required the patient to be reviewed by a doctor and extra monitoring, supervision or treatment ordered. In 2006-07 one in ten Behaviour incidents led to an increased length of stay in hospital, permanent disability or death compared to almost one in five in 200708. Twelve patient deaths in 2006-07 and thirteen patient deaths in 2007-08 were associated with Behaviour incidents. The most common type of Behaviour incidents related to physical abuse, verbal abuse and absconding with the highest rate occurring in the 15-34 year age group for 2006-07 and in the 20-34 year age group for 2007-08 and involved males more than females. Mental health was documented as the contributing factor for over half of all reported Behaviour incidents. Since 2001-02 the number of Behaviour incidents associated with alcohol or drug intoxication reported to AIMS has increased.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Strategies have been implemented to decrease the number of Behaviour incidents. These include: a) for patients at a high risk of self-harm, removal of hanging points from mental health facilities, and increased staff observation or 1:1 specialling. b) for violent patients, chemical/physical restraint or seclusion. These strategies are designed not only to protect the patient but also to protect the staff and other patients from harm.
Incidents Classified as Other Incidents that could not be classified into one of the other nine PITs were categorised as Other. There were 3,253 Other incidents in 2006-07 representing the third most frequently reported type of incident to AIMS compared with 3,499 Other incidents in 2007-08 representing the fourth most frequently reported type of incident to AIMS. Fifty one patient deaths resulted from Other incidents in both 2006-07 and 2007-08. The Other incident type is divided into eight sub-categories including a sub-category called Other for non-classifiable incidents. Patient deaths were associated with the following Other sub-categories: o Medical emergency o No or delayed admission, inappropriate bed or ward o No or wrong or delayed diagnosis o No, wrong or delayed procedure, treatment or assessment o Other o Poor discharge planning.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Injury The fifth most commonly reported category of clinical incidents was Injury. There were 2,295 injury incidents reported in 2006-07, representing a rate of 1.5 incidents per 1,000 bed days compared with 2,492 incidents reported in 2007-08, representing a rate of 1.6 incidents per 1,000 bed days. The majority of Injury incidents (93.5% 2006-07 and 95.1% 2007-08) required the patient to be reviewed by a doctor with extra observations and monitoring and / or treatment / diagnostic investigations ordered (e.g. x-ray, dressing, analgesia). A small proportion of these incidents (1.8% 2006-07 and 2.6% 2007-08) resulted in an increased length of stay in hospital or permanent disability. None of these incidents were associated with a patient death in 2006-07 however three patient deaths resulted from Injury incidents in 2007-08. Pressure ulcers were the most frequently reported type of injury with 749 such incidents notified in 2006-07 compared with 809 incidents notified in 2007-08. Patient co-morbidities, such as poor health and frailty were noted as a contributing factor in almost half of all Injury incidents. The number of reported Injury incidents increased with age, with the highest rate associated with those over 85 years (3.7 per 1,000 bed days 2006-07 and 3.4 per 1,000 bed days for 2007-08). Strategies have been implemented to decrease the number of Injury incidents. These include the training of staff to reinforce knowledge of pressure ulcer formation and how to avoid such incidents.
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Clinical incidents resulting in serious and / or permanent harm or death are investigated using Root Cause Analysis or other similar methodology. In this way contributing factors can be discovered, recommendations implemented and lessons learned shared across health services to prevent such incidents from occurring again.
WA Health continues to encourage the notification and investigation of clinical incidents through the AIMS process so as to improve the safety and quality of patient care. Other systems, the WA Review of Mortality (WARM),2 the Sentinel Event Program 3 and the WA Audit of Surgical Mortality (WAASM)4 are also in place to capture and share information on catastrophic clinical incidents to prevent them from occurring again.
1. Introduction
An 81-year old man was admitted to hospital with severe hypoglycaemia and a history of episodic confusion. On the second day of his hospital stay, the patient experienced dizziness and confusion. He then proceeded to walk out of the room at which point he fell and sustained a broken hip and three broken ribs. Surgery was required to correct the fractured hip and the patient spent the following three months receiving acute inpatient care and rehabilitation. Despite regaining his mobility, the patient still had residual disability 12 months on and has not returned to his previous level of function.
Subsequent recommendations from the investigation of the incident concluded that all elderly patients should receive a falls risk assessment and that preventative falls measures be put in place.
This is a composite incident based on events notified to the Advanced Incidents Management System (AIMS).
The Western Australian community enjoys an excellent standard of healthcare. The range of services and advances in treatments requires a health system that can constantly adapt to meet current and future challenges. Healthcare is an inherently risk-laden endeavour. While the continual growth of technical complexity increases the benefits of clinical interventions, it also represents an increasing range of risks to patients. It is estimated that approximately 10% of hospital admissions result in a preventable clinical incident.5-8 Clinical incidents alone are predicted to cost healthcare providers between $483 million9 and $900 million10 annually.
This combined annual report documents the key features and trends of the top five clinical incident types notified to the Advanced Incident Management System (AIMS) in Western Australia in 2006-07 and 2007-08. AIMS is a voluntary clinical incident reporting system that has been in place in metropolitan and country WA public health services since October 2001. This is one of several systems used by WA Health to capture clinical incidents and adverse events and facilitates the notification,
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 investigation, analysis and recommendation monitoring of the clinical incidents that occur in public inpatient and outpatient healthcare settings. Information collected in compliance with the Sentinel Event Policy3 and the WA Review of Mortality Policy2 may also be reflected in AIMS. The process of clinical incident management enables changes to be implemented at the clinical service delivery level to prevent future incidents and improve patient safety.
Clinical incidents and adverse events have proven challenging to measure in a voluntary system. A change in the level of reporting by hospitals may reflect local improvement activities, reporting practices or incident rates. This poses a difficulty in interpreting or comparing the number of incidents between hospitals or across Area Health Services. In particular, WA Health encourages the notification of all incidents and is currently implementing a number of patient safety initiatives to improve reporting and awareness amongst healthcare workers. Therefore, increases in the number of notified clinical incidents are welcomed as they may be indicative of an emerging culture of reporting and an increased willingness to learn from incidents and make changes to prevent their recurrence.
Communication remains a key component to improving safety and quality in healthcare. This report seeks to inform the WA community of incidents that have occurred within our health system and the measures that are being taken to prevent their recurrence.
The notification of clinical incidents reflects the dedication of WA Health clinicians and administrators to patient safety and quality of care. WA Health remains committed to the creation and maintenance of a culture of safety and improvement within our healthcare system.
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2. Methodology
Clinical incidents are collected and recorded via the AIMS version 2.4 software. All public hospitals and one private hospital in Western Australia use the system.
AIMS is a voluntary reporting system whereby staff, patients, clients, carers or visitors who witness a clinical incident are encouraged to report it using a clinical incident form. Incidents are notified from in-patient and out-patient settings across WA and are then classified, for reporting and analysis purposes, into one of the ten Principal Incident Types (PITs): Behaviour Blood, oxygen, gas Documentation Falls Injury Medication Nutrition Other Safety and security Therapeutic devices or equipment.
Once a clinical incident is notified to AIMS, it is investigated by the health service where the incident occurred. The process is defined by the Department of Healths Clinical Incident Management Policy.11 Once investigations are complete, incidents are classified according to the severity of the outcome to the patient on a scale of 1-8 (see Outcome Level table in Appendix B). An Outcome Level of 1-2 is defined as a near miss resulting in no harm to the patient. Outcome Levels 3-8 refer to events of increasing severity that directly affect the patient ranging from no harm (Outcome Level 3) to significant or severe harm, i.e. permanent disability or death (Outcome Level 8).
The identification of actual or potential breakdowns in healthcare systems and their investigation enables remedial action to be taken to prevent incidents occurring in the
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 future. Implementation of recommendations arising from investigations, are monitored by the healthcare facility where the incident occurred.
Data for 2006-07 was extracted from the AIMS data base in May 2008 and for 200708 the data was extracted in July 2009 with the key features and trends of the top five clinical incident types identified and reported here. The incident types are reported in order of frequency of events captured in AIMS from most to least frequent. Since AIMS is a voluntary notification system it should be emphasised that the clinical incidents reported here are only those notified to the system.
The limitations of AIMS data are outlined in the Caveats section in Appendix A
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3. Results
3.1 General Overview
At the time of the 2006-07 data analysis there were 128,962 incidents contained in the AIMS database of which a total of 23,586 were entered and classified during the 200607 financial year.
At the time of the 2007-08 data analysis there were 189,075 incidents contained in the AIMS database of which a total of 27,322 were entered and classified.
The number of incidents and the relative proportion of each of the ten PITs are shown in Table 1.
Table 1: Number and Percent of Incidents reported to AIMS in 2006-07 and 200708 by the Ten Principal Incident Types
Principal Incident Type Falls Medication Behaviour Other Injury Documentation Therapeutic devices Safety or Security Blood, Oxygen or Gas Nutrition
2006-07 6,409 27.0% 5,570 24.0% 2,884 12.0% 3,253 14% 2,295 10% 1,145 5.0% 1,288 5.0% 497 2.0% 85 0.4% 160 1.0%
2007-08 6,823 25.0% 6,416 23.5% 3,844 14.1% 3,499 12.8% 2,492 9.1% 1,823 6.7% 1,454 5.3% 693 2.5% 92 0.3% 186 0.7%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 As can be seen in Table 1, Falls incidents and Medication incidents made up approximately half (51% 2006-07 and 48.5% 2007-08) of all incidents reported to AIMS for this time period, with Behaviour, Other and Injury incidents accounting for a further 36.0% of all reported events.
Figure 1 shows the incident trends for the top five PITs between 2001-02 and 200708. Note that the data for 2001-02 is not a full year as AIMS was introduced in October 2001.
Figure 1: Trends in the Top Five Principal Incident Types in AIMS between 200102 and 2007-08
9,000 8,000 7,000 Number of Incidents 6,000 5,000 4,000 3,000 2,000 1,000 0 2001-02 2002-03 Falls 2003-04 Medication 2004-05 2005-06 Other 2006-07 Injury 2007-08
Behaviour
Since 2001-02 Falls and Medication incidents have consistently been the PIT categories with the greatest number of reported incidents while Behaviour, Injury and Other incidents (incidents that cannot be classified into one of the other nine incident types) have consistently ranked between the 3rd and 5th most reported incidents in the AIMS database.
The remainder of this report focuses on these top five PITs.
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3.2 Falls Incidents

3.2.1 Introduction The World Health Organisation defines a fall as an event which results in a person coming to rest inadvertently on the ground or other lower level.12 Falls are associated with advanced age, frailty, altered mental or cognitive status, and post-orthopaedic surgery.13-20 Of these, the most significant risk factor associated with falls is advanced age. Several national and international studies have identified that approximately 17% to 33% of people aged 65 or older fall each year in the community,21-22 and it is estimated that this rate is even higher in the acute care setting.13-14, 21 Falls are associated with increased morbidity, length of stay and healthcare costs.18,
22-23
The Victorian Department of Health estimated that the cost of falls in Victorian
hospitals totalled $82.5 million per year with a mean cost of $4,580 per fall.1
3.2.2 Results Falls Incidents 2006-07 and 2007-08 From July 1 2007 to 30 June 2008 there were 6,823 falls notified to AIMS, representing one quarter (25.0%) of all incidents for the period. There were 414 fewer Falls incidents notified to AIMS in 2007-08 compared to 2006-07, a decrease of 5.7%.
Trends in Falls Incidents in 2001-08 Since the inception of the AIMS database in 2001, Falls incidents have consistently been the most notified incident type, with an average of 6, 586 incidents reported per year.
There has been a downward trend in both the number and rate of falls reported to AIMS since 2005-06 (Table 2) from 5.0 falls per 1,000 bed days to 4.4 in 2007-08.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Table 2: Number and Rate of Falls Incidents Notified Per Year 2001-08 1
Number of Falls Incidents 4,419 7,856 7,685 7,377 7,428 6,409 6,823 Number of Bed Days 1,393,388 1,477,925 1,446,603 1,513,179 1,491,433 1,494,006 1,548,462 Rate/1,000 Bed Days 3.2 5.3 5.3 4.9 5.0 4.3 4.4
2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08
In addition, the number of falls notified as a proportion of the total number of incidents has decreased since 2001 (Figure 2). In 2001-02, falls represented 41.2% of all incidents compared to 25.0% in 2007-08. Further analysis of the data demonstrates that while the majority of hospitals displayed a stable reporting rate for falls, two tertiary and one non-tertiary metropolitan hospital displayed significant reductions in the number of falls since 2001 with these hospitals accounting for the decline in numbers notified to the system. Figure 2: Falls Incidents as a Proportion of All Notified Incidents 2001-08
100% 90% Percentage of Total Incidents 80% 70% 60% 50% 40% 30% 20% 10% 0% 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08
Falls Incidents
Not Falls Incidents
Implementation of AIMS commenced in October 2001, therefore data for 2001-02 is not for a full year.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Furthermore, analysis of Falls incident Outcome Levels demonstrates that notification of Falls incidents with minor harm (Outcome Level 4 incidents) have been decreasing since 2002-03 (Figure 3).
Figure 3: Number of Falls Incidents by Outcome Level and Year 2002-08

4,500 4,000 Number of Falls Incidents 3,500 3,000 2,500 2,000 1,500 1,000 500 0 Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Level 7 Level 8 Outcome Level 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08
Outcome of Falls Incidents The majority of falls (80.4% 2006-07 and 83.4% 2007-08) were associated with a minor to moderate level of harm to the patient requiring review by a doctor and extra monitoring or minor diagnostic investigations or treatment (e.g. x-ray, dressings, analgesia) (Figure 4a and 4b). Two percent (2.0%) of all Falls incidents for both time periods were associated with significant to severe harm (e.g. an increased length of stay in hospital, permanent disability or death). There were four patient deaths in 2006-07 and seven patient deaths in 2007-08 associated with falls.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 4a: Percent of Falls Incidents by Outcome Level Category 2006-07
2.0% 17.6%
80.4%
No Harm (Outcome Level 1-3) Minor to Moderate Harm (Outcome Level 4-6) Significant to Severe Harm (Outcome Level 7-8)
Figure 4b: Percent of Falls Incidents by Outcome Level Category 2007-08

2.0%
14.6%
83.4%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Over half of all falls (53.2%) resulted in no injury to the patient in 2006-07 and less then half of all falls (44.2%) resulted in injury 2007-08. As indicated in Figures 5a and 5b, approximately one quarter (25% 2006-07 and 24.6% 2007-08) of falls caused the patient to suffer an abrasion, laceration or skin tear, 11.2% resulted in bruising, swelling or reddening, and 11.0% were associated with pain in 2006-07 .
Figure 5a and 5b also show that 1.8% of falls resulted in a fracture or dislocation for 2006-07 and 2007-08.
Figure 5a: Number and Percent of Falls Incidents by Type of Associated Injury 2006-072
1800 1600 1400 Number of falls 1200 1000 800 600 400 200 0
25.3%
12.3%
12.1%
2.3%
1.8%
1.7%
1.1%
0.1%
la ce ra tio
w el lin
Fr ac tu r
is e, s
Al te re
Br u
A fall can be associated with more than one injury category.
Ab r
as io ns
Al te
re d
or
le ve lo
fc on ci ou sn es s Sp ra in or st ra in
ed de ni ng
or di sl o
or s
em ot io
ns
or r
na ls ta te
Pa in
ki n
ca ti o n
te ar
th er
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 5b: Number and Percent of Falls Incidents by Type of Associated Injury 2007-08 3
1,800 Number of Falls Incidents 1,600 1,400 1,200 1,000 800 600 400 200 0
Pa in ar ea st at fc e on cio us ne Sp ss ra in or st ra in O th er te ar oc at io n
3.2% 1.8% 12.8% 11.1% 24.6%
1.2%
1.0%
0.2%
ed de ne d
sk in
ac er at io ns
or d
or r
Fr ac tu re
em Al
we llin g
Al
Ab ra sio ns
The literature indicates that falls which result in a fracture are more likely to occur in older as opposed to younger patients.19, 24 This is evidenced in the 2007-08 AIMS falls data where, of the falls resulting in a fracture, the age of patients ranged between 0 years to 99 years with a median age of 82 years. Similarly, of all the falls resulting in hip fractures, the age of patients ranged from 61 to 94 years with a median age of 83 years.
Table 3 outlines the 19 falls incidents (0.3% of all falls incidents) in 2006-07 and 90 Falls incidents in 2007-08 (1.3% of all falls incidents) that resulted in a fracture. For both 2006-2007 and 2007-2008 the majority of falls resulted in a fracture of the hip, neck of femur or trochanter.
A fall can be associated with more than one injury category.
Br ui s
e, s
te re d
or l
le ve lo
te re d
ot io na l
or
isl
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Table 3: Number of Falls Incidents Resulting in a Fracture by Fracture Type 2006-07 and 2007-08
Outcome Hip/Neck of Femur/Trochanter Shoulder/Arm/Wrist Leg/Knee Skull/Nose/Mandible/Face Vertebrae Ankle/Foot Pelvis Ribs Probable fracture TOTAL Number of Falls Incidents 2006-07 2007-08 13 37 2 18 12 2 8 5 4 1 3 3 1 19 90
Nature and Location of Falls Incidents Nearly a third of all falls reported in 2006-07 (29.1%) and just over a quarter of falls reported in 2007-08 (26.8%) were associated with a fall on the same level, for example while walking or standing (Figures 6a and 6b). This was followed by falls classified as unknown origin (16.7% in 2006-07 and 18.1% 2007-08) and other mechanism of fall (15.9% 2006-07 and 16.7% 2007-08). Figure 6a: Number and Percent of Falls Incidents by Category of Falls 2006-07 4
2,000 1,800 1,600 1,400 Number of falls 1,200 1,000 800 600 400 200 0
oo ch m ai ro rw O n he w el et ch or ai sl r ip pe ry su Fr rfa om ce to il e to Fr rc om om th m er od ap e eu ti c eq ui pm en t al l or ig in to il e t le ve l ot of F er or ba th r an is m or fro m e be d n sa m n O st ai rs or c
29.1%
16.7%
15.9% 13.8% 13.1% 10.8% 8.5% 4.3%
3.8% 0.5% 0.4%
nk no w
th er M ec h
Fr om
to et tin g
sh ow In
A fall can be associated with more than one category.
Fr om
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 6b: Number and Percent of Falls Incidents by Category of Falls 2007-08 5
2,000 1,800 Number of Falls Incidents 1,600 1,400 1,200 1,000 800 600 400 200 0
e le Un ve O k l th no er wn M or ec ig ha in ni sm of Fr Fa om ll G et be t in d g or to co or t In fro sh m ow to er ile Fr t or om ba ch th ro ai O ro om n rw we he to el rs ch lip ai Fr pe r om ry s to ur Fr ile fa om ce to rc th om er ap m eu od t ic e eq ui pm en t O n st ai rs
18.1% 16.7% 11.9% 26.8%
10.8%
9.7%
8.4% 3.9%
2.9% 0.5% 0.3%
Patient Demographics The number of falls in 2006-07 and 2007-08 increased with patient age (Figure 7a and 7b). Approximately three quarters of all falls involved patients aged 65 years and over (76.8% in 2006-07 and 73.0% for 2007-08). This was also reflected in the rate of falls per 1,000 bed days. For patients aged less than 39 years the rate ranged from 0.8 to 1.3 falls per 1,000 bed days in 2006-07 to 1.0 to 1.4 falls per 1,000 bed days for 200708. For patients aged 65 years and over the falls rate ranged from 4.1 to 10.8 per 1,000 bed days in 2006-07 to 4.4 to 9.7 per 1,000 bed days for 2007-08. This data demonstrates that older patients have a greater risk of falling than younger patients.
A fall can be associated with more than one category.
O n
sa m
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 7a: Number and Rate of Falls Incidents by Age Groups 2006-07
2,000 1,800 10 1,600 1,400 8 Number of falls 1,200 1,000 800 4 600 400 2 200 0
10 -1 4 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 60 -6 4 65 -6 9 70 -7 4 75 -7 9 80 -8 4 085 + 4 59
12
Age Group Number of falls Number of falls per 1000 bed days
Figure 7b: Number and Rate of Falls Incidents by Age Group 2007-08
1,800 1,600 Number of Falls Incidents
12 10 Rate of Falls Incidents per 1,000 Bed Days
1,400 1,200 1,000 6 800 600 400 2 200 0

ye 5- ars 9 10 yea -1 r 4 s 15 yea -1 rs 9 20 yea -2 rs 4 25 yea -2 rs 9 30 ye -3 ars 4 35 ye -3 ars 9 40 ye -4 ars 4 45 yea -4 rs 9 50 yea -5 rs 4 55 ye -5 ars 9 60 ye -6 ars 4 65 yea -6 rs 9 70 yea -7 rs 4 75 yea -7 rs 9 80 yea -8 rs 4 ye a 85 rs + ye ar s
04
Age Group Number of Falls Incidents Rate of Falls Incidents per 1,000 Bed Days
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Rate of falls per 1,000 bed days
Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 With regard to gender, the rate of falls for males was consistently higher than females across the different age categories (Figure 8a and 8b). In 2006-07, the falls rate for males aged between 65-69 years was calculated at 4.5 falls per 1,000 bed days while for those aged 85 years or more, the falls rate was 12.6 falls per 1,000 bed days. In 2007-08 results for males in the previously mentioned age groups showed rates of 4.8 falls per 1,000 bed days and 12.2 falls per 1,000 bed days respectively.
Compared to males in 2006-07 the rate of falls for females was lower for those aged between 65-69 years (3.4 falls per 1,000 bed days) and also for those aged 85 years or more (9.6 falls per 1,000 bed days). Results for 2007-08 also showed lower falls rates for females aged between 65-69 years (3.7 falls per 1,000 bed days) and for those patients 85 years or more (8.2 falls per 1,000 bed days).
Figure 8a: Rate of Falls Incidents Per 1,000 Bed Days by Age Group and Gender 2006-07
14 Rate of falls per 1,000 beddays by gender 12 10 8 6 4 2 0
ye ar s ye 10 a to rs 14 15 ye ar to s 19 ye 20 a to rs 24 ye 25 ar to s 29 30 ye ar to s 34 ye 35 a to rs 39 40 ye ar to s 44 ye 45 a to rs 49 50 ye ar to s 54 ye 55 ar to s 59 60 ye a to rs 64 ye 65 ar to s 69 ye 70 ar to s 74 75 ye a to rs 79 ye 80 ar to 85 s 84 ye y ar e ar s an s d ab ov e to 09
to 0
05
04
Age Group Female Male
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 8b: Rate of Falls Incidents per 1,000 Bed Days by Age Group and Gender 2007-08
Rate of Falls Incidents per 1,000 Bed Days
14 12 10 8 6 4 2 0
ye ar s 9 ye 10 ar s -1 4 ye 15 ar -1 s 9 ye 20 ar s -2 4 ye 25 ar s -2 9 ye 30 ar s -3 4 ye 35 ar s -3 9 ye 40 ar s -4 4 ye 45 ar s -4 9 ye 50 ar s -5 4 ye 55 ar s -5 9 ye 60 ar -6 s 4 ye 65 ar s -6 9 ye 70 ar s -7 4 ye 75 ar s -7 9 ye 80 ar s -8 4 ye ar 85 s + ye ar s 5-
0-
Age Group Rate of Falls per 1,000 bed days - Female Rate of Falls per 1,000 bed days - Male
Contributing Factors In 2006-07 and 2007-08 94% of the contributing factors associated with falls were attributed to patient related factors. Table 4 indicates the patient contributing factors for falls and the proportion of falls with that contributing factor. Almost half (49.0% 2006-07 and 48.6% 2007-08) of all patients who fell had a co-morbidity that contributed to the fall. Co-morbidities can include dementia, confusion, disorientation, frailty and poor balance.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Table 4: Number and Percent of Falls Incidents by Type of Patient Contributing Factor 2006-07 and 2007-08 6
Contributing Factor Patient CoMorbidities Physical impairments Other Failure to follow advice or instructions Confusion or disorientation Dementia Very ill, frail, debilitated or general deterioration Unsteady on feet Cerebrovascular accident or Transient Ischaemic Accident Affected by medication Wrong or no footwear Language or speech barriers Mental health related Alcohol or drug intoxication Distraction or inattention 2006-07 Number Proportion Contributing of Falls of All Falls Factor Patient Co3,142 49.0% morbidities Physical 2,745 42.8% impairments 2,424 37.8% Other Failure to follow 1,899 29.6% advice or instructions Confusion or 1,583 24.7% disorientation 1,320 20.6% Dementia 728 11.4% Unsteady on feet Cerebrovascular accident or transient ischaemic accident Very ill, frail, debilitated or general deterioration Wrong or no footwear Affected by medication Language or speech barriers Mental health related Distraction or inattention Alcohol or drug intoxication 2007-08 Number Proportion of Falls of All Falls 3,317 2,568 1,895 1,744 1,508 1,264 760 48.6% 37.6% 27.8% 25.6% 22.1% 18.5% 11.1%
727
11.3%
575
8.4%
529
8.2%
556
8.2%
401 356 217 133 38 33
6.3% 5.6% 3.4% 2.1% 0.6% 0.5%
418 376 236 167 54 51
6.1% 5.5% 3.5% 2.4% 0.8% 0.7%
3.2.3 Discussion While the number of falls notified to AIMS has decreased over time, Falls remain the most notified clinical incident in WA.25 The high proportion of Falls incidents is also reflected in national and international reports.13, 15-18, 20, 23, 25-30 Based on the Victorian estimate of $4,580 per fall, in 2007-08 alone, the estimated cost to WA Health of falls
6
A fall can be associated with more than one contributing factor.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 notified to the WA Advanced Incident Management System was over $33 million. Falls are therefore a significant cost issue for WA Health.25, 31 There are several possible explanations for the decrease in Falls incidents over the past six years. First, the reduction may be a direct result of the implementation of falls initiatives such as the Safety and Quality Investment for Reform (SQuIRe) Falls Clinical Practice Improvement (CPI) program.32 There are two tertiary and one nontertiary metropolitan hospitals that have implemented this program and shown a decline in the number of Falls incidents. Secondly, the decrease may also be due to health services focussing reporting efforts on falls with more significant outcomes. This explanation is supported by the overall reduction in the number of Outcome Level 4 events (Figure 4).
The majority of falls (80.4% 2006-07 and 83.4% 2007-08) required the patient to be reviewed by a doctor with extra monitoring or minor diagnostic investigations or treatment ordered (e.g. x-ray, dressings, analgesia), while 17.6% (2006-07) and 14.6% (2007-08) of falls were classified as having resulted in no harm to the patient. This differs to reports from the United Kingdom (UK)13 where almost two thirds of falls in acute care hospitals were associated with no harm, and 29.5% with minor harm. This variation may be due to their falls prevention programs or, amongst other things, due to differences in classifying the consequences of falls, or hospitals in the UK reporting a greater proportion of falls associated with no harm compared to WA public hospitals.
AIMS data on fractures showed 19 incidents (0.3% of all Falls incidents in 2006-07) and 90 incidents (1.3% of all Falls incidents in 2007-08) resulted in fracture. This compares to data presented by the National Patient Safety Agency (UK)13 that demonstrated 0.7% of all falls in acute care hospitals resulted in severe harm including fractures. While these numbers may seem small, the outcome of such incidents to the patient is significant. For example, research has shown that older patients who fracture their neck of femur fail to recover their previous level of mobility or independence.19, 33
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 A patient can experience a fall during a range of activities, including walking, standing, sitting, or lying in bed. The greatest proportion of falls (29.1% 2006-07 and 26.8% 2007-08) occurred on the same level, that is, when the patient was standing or walking. This data is consistent with falls reported by the National Patient Safety Agency.13 WA data also indicated that 13.1% (2006-07) and 10.8% (2007-08) of falls occurred when a patient was getting to or from a toilet, and 3.8% (2006-07) and 2.9% (2007-08) of falls occurred from a toilet or commode. These results confirm research findings demonstrating that toileting14-15, 17 and urinary incontinence34 are associated with an increased fall risk. A significant proportion of falls reported here and elsewhere15 were of unknown origin.
Advanced age, male gender, physical impairments, frailty, and altered cognitive status are documented fall risk factors.13-15, 17-19, 21, 29 WA data demonstrated advanced age to be a significant risk factor for a fall (Figure 7a, 7b, 8a and 8b). In general, males have a greater risk of falling compared to females across most age groups, although the gender difference was not large. The higher rate of falls in males compared to females was also demonstrated in the UK13 and USA29 in-patient falls data.
Other patient factors have also been identified as increasing the risk of a fall. International literature on falls has demonstrated the risk of falls increases with physical impairment, physiological factors, co-morbidities and cognitive impairment.1314, 16-17, 20-21
This was also reflected in WA with almost half of all falls associated with a
co-morbidity. Almost one fifth (20.6% 2006-07 and 18.5% 2007-08) of falls were associated with patients who suffered from dementia.
The Falls incident data presented in this report, as well as data presented in national and international reports on falls, demonstrate that this type of clinical incident has great significance to health services around the world. The incidents recorded in the AIMS database also include actions taken and recommendations made to decrease the number and severity of these incidents in the WA public health system. Some examples of actions taken in WA in 2006-07 and 2007-08 are outlined below.
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3.2.4 Key Messages Based on falls reported to AIMS in 2006-07 and 2007-08 the following are examples of changes made in WA Health to decrease the risk of patients falling: Development and implementation of Falls Risk Assessment Tools (FRAT) Increased supervision of patients rated as having a high risk of falling Patients at risk of falling nursed in low beds Active participation by health services in improvement initiatives such as SQuIRe and the Falls Prevention Network.
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3.3 Medication Incidents

3.3.1 Introduction The term medication incident refers to any preventable event in which medication is prescribed or administered incorrectly.35-36 The quantity of medications administered in the hospital setting is a significant factor, with almost all patients receiving some form of medication during their stay.37 Whilst the majority of prescriptions and drug administrations occur without incident, missed doses, overdoses, and wrong prescriptions remain a persistent and widespread clinical problem.38
Medication incidents can be classified into two broad categories, prescription/dispensing errors and administration errors.35-36 Human error is a significant contributor to medication errors and can result from personal issues (e.g. tiredness, stress); contextual issues (e.g. shortage of staff, heavy workloads) and knowledge based issues (e.g. inexperience and lack of knowledge of medications, mathematical errors).39-41 In a study conducted to identify the system failures that contribute to Medication incidents, Leape et al., reported 39% of mistakes are associated with prescribing, 38% occur during administration and 23% are attributable to transcribing/compounding errors in the pharmacy.42 Compliance with guidelines, procedures and policies governing the administration and dispensing of drugs in a clinical setting remains an issue in Medication incidents.35, 41
Fortunately, most errors are detected before administration (i.e. a near miss) and the majority of Medication incidents cause no harm to the patient.35 According to Song et al.,43 less than 0.1% of medication errors result in serious morbidity or mortality to the patient. It is believed that approximately 1 in 853 in-patient deaths and 1 in 131 outpatient deaths are a result of medication errors.44 Incidents are more likely to occur in children, the elderly, nursing home residents, patients admitted to intensive care and the cognitively impaired.45-47
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 3.3.2 Results Medication Incidents 2006-07 and 2007-08 Between 1 July 2007 and 30 June 2008 there were 6,416 Medication incidents notified to AIMS, representing a 13.2% increase in notifications (846 more) compared to 200607. Medication incidents made up almost one quarter (23.5%) of all reported incidents in 2007-08.
Trends in Medication Incidents 2001-08 Since the inception of AIMS data collection in 2001, Medication incidents have consistently been the second-most notified type of incident, with an average of 5,351 incidents reported per year.
Between 2001-02 and 2005-06 there was an upward trend in the number and rate of reported incidents (Table 5) with the rate ranging from 1.7 to 4.2 incidents per 1,000 bed days. In 2006-07 the rate declined to 3.7 incidents per 1,000 bed days and increased slightly in 2007-08. Table 5: Number and Rate of Medication Incidents Notified Per Year (2001-08) 7
2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 Number of Medication Incidents 2,325 5,209 5,566 6,038 6,335 5,570 6,416 Number of Bed Days 1,393,388 1,477,925 1,446,603 1,513,179 1,491,433 1,494,006 1,548,462 Rate/1,000 Bed Days 1.7 3.5 3.8 4.0 4.2 3.7 4.1
The proportion of all clinical incidents classified as Medication incidents ranged from 21.6% in 2001-02 to 24.0% in 2006-07 and 23.5% in 2007-08.
Implementation of AIMS commenced in October 2001, therefore data for 2001-02 is not for a full year.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Outcome of Medication Incidents Consistent with the literature, over half of all reported Medication incidents (56.8% 2006-07 and 59.1% 2007-08) were associated with no harm to the patient (Figures 9a and 9b). Medication incidents that were associated with minor to moderate levels of harm requiring review by a doctor and extra monitoring or minor diagnostic investigations or treatment (e.g. blood tests), represented 42.1% (2006-07) and 39.8% (2007-08) of all incidents. One percent (1.0%) of incidents was associated with significant to severe harm (e.g. an increased length of stay in hospital, or permanent disability or death). Three Medication incidents were associated with a patient death in 2006-07 and four in 2007-08. Figure 9a: Percent of Medication Incidents by Outcome Level Category 2006-07
1.0%
42.1%
56.8%
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Figure 9b: Percent of Medication Incidents by Outcome Level Category 2007-08
1.0%
39.8%
59.1%
Type of Medication Incident Almost one third of Medication incidents (31.7% 2006-07 and 30.7% 2007-08) were due to missed doses (omissions) (Figures 10a and 10b).
Overdoses of medication represented 16.6% (2006-07) and 15.3% (2007-08) of incidents and the wrong medication, additive or fluid was administered in 12.0% (2006-07) and 11.9% (2007-08) of incidents.
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Number of Medication Incidents
W ro
Number of medication incidents

W ro ng
1,000 200 400 600 800 0 1,200 1,400 1,600 1,800 2,000
1,000
1,200
1,400
1,600
1,800
2,000
ng
200
400
600
800
m ed i on
O m is si
ca t io
30.7%
m ed ic
O m iss
at io
31.7%
16.7% 15.3%
16.7% 16.6%
11.9%
12.0%
5.7% 4.9% 3.9% 3.8% 2.7% 2.2% 2.1%
5.4% 4.6% 4.1% 3.6% 2.9% 2.3%
Figure 10b: Number and Percent of Medication Incident Types by Type of Medication Incident Category 2007-08 8
Figure 10a: Number and Percent of Medication Incidents by Type of Medication Incident Category 2006-07 8
A medication incident can have more than one category assigned.

Type of Medication Incident
2.0% 1.8% 1.8% 1.5% 1.2%
Type of Medication Incident

1.9% 1.8% 1.5% 0.8% 0.8% 0.7% 0.4% 0.3% 0.1%
O th n, ad Ove er di rd tiv os e G iv or e en f bu Und luid tn er ot do W sig se ne ro ng d fre f or q D ue W DA ro Wro nc ng ch ng y ec in fu ti m k no s e td W ion ra o n ro t n e e or g p a di sc ti en R re t ea p an W ct ro io cy ng n t G o m rou i ve ed te N n o w i ca or in itho tion co ut r Ex rec ord tl e pi Se red abe r llin lf m in Pr e g fli ob ct dica le ed t i m ov on du e ri n Th rdo g th eft se er o ap r lo D am eut ss ag ic u se ed pr od uc t
io n O n, t h ad Ov er di erd tiv e o se o W Un r flu ro de id ng rd G DD fre os iv qu e en A ch bu Wr en ec c o t k W n o ng y no r o t s tim t d ng ig e on in ne fu d f e or sio or di sc n ra W r ep te r o an ng cy G W pat i v r i Re e en o t ac n w ng No tion ith ro u ou te o r to t m or in Se co e d de r r i c r lf Pr in ect atio ob f li ct lab n le E ed e m x du pir e ov lling e rin d g me rdo th s d er ica e ap tio eu n t Da The ic u m ft o s e ag ed r lo pr ss od uc t
0.8% 0.6% 0.4% 0.3% 0.3%
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Omission Incidents In 2006-07, Warfarin sodium (4.3%), Heparin (2.4%), Frusemide (3.6%), Paracetamol (3.6%) and Gentamicin (3.5%) were the most frequently omitted medications (Table 6). While in 2007-08 the five most commonly omitted medications were Paracetamol (5.4%), Warfarin sodium (3.9%), Heparin (3.0%), insulin (3.0%) and Frusemide (2.5%).
Table 6: Top 10 Medications Involved in Omission Incidents in WA 2006-07 and 2007-08 9

2006-07 Number of Medication incidents Warfarin sodium 82 (4.3%) Frusemide Paracetamol Gentamicin Heparin Insulin Oxycodone hydrochloride Aspirin Flucloxacillin Dexamethasone 68 (3.6%) 68 (3.6%) 67 (3.5%) 45 (2.4%) 42 (2.2%) 42 (2.2%) 38 (2.0%) 36 (1.9%) 34 (1.8%) 2007-08 Number of Medication incidents 107 (5.4%) Paracetamol Warfarin 76 (3.9%) sodium 59 (3.0%) Heparin 59 (3.0%) Insulin Frusemide Hydroxocobal amin chloride Gentamicin Enoxaparin sodium Perindopril erbumine Oxycodone hydrochloride 49 (2.5%) 44 (2.2%) 43 (2.2%) Antibiotic 39 (2.0%) 38 (1.9%) 35 (1.8%) Anticoagulant Antihypertensive Opioid analgesic
Rank
1 2 3 4 5 6 7 8 9 10
Medication class Anticoagulant Diuretic Analgesic Antibiotic Anticoagulant Insulin preparations Opioid analgesic Anticoagulant Antibiotic Steroid
Rank
1 2 3 4 5 6 7 8 9 10
Medication class Analgesic Anticoagulant Anticoagulant Insulin preparations Diuretic Parenteral vitamin
Figures 11a and 11b show the proportion of omission incidents falling into each of the AIMS Outcome Level categories.
Data for both reporting years showed that the majority of medicine omissions resulted in no harm to the patient (60.8% 2006-07 and 64.5% 2007-08). With less than one percent of omissions associated with significant or severe harm to the patient (0.7% 2006-07 and 0.9% 2007-08).
An incident can be associated with more than one type of medication.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 11a: Percent of Omission Incidents by Outcome Level Category 2006-07
0.7% 38.5%
60.8%
Figure 11b: Percent of Omission Incidents by Outcome Level Category 2007-08

0.9% 34.4%
64.5%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 In 2006-07 the four most common causes of omission incidents were failure to read or misread (48.6% of all omission incidents), failure to follow policy or procedure (37.2%), prescription or order error (14.5%) and unclear or incomplete order (12.9%; Table 7).
In 2007-08 the four most common causes of omission incidents were failure to read or misread (41.0% of all omission incidents), failure to follow policy or procedure (40.3%), unclear or incomplete order (13.6%) and other (cause does not fit into any defined category) (12.4%). Table 7: Percent of Omission Incidents by Causes of Omission Incident Category 2006-07 and 2007-08 10
2006-07 Cause of Incident Proportion of Omission Incidents Failure to read or 48.6% misread Failure to follow 37.2% policy or procedure Prescription or 14.5% order error Unclear or 12.9% incomplete order Other New order overlooked Medication not available Dispensing error Patient self medicating Previous known adverse reaction 11.5% 3.6% 3.4% 0.9% 0.7% 0.1% 2007-08 Cause of Incident Proportion of Omission Incidents Failure to read or 41.0% misread Failure to follow 40.3% policy or procedure Unclear or 13.6% incomplete order Other Medication not available Prescription or order error New order overlooked Patient self medicating Dispensing error Incorrect calculation 12.4% 7.4% 5.8% 2.1% 0.4% 0.3% 0.1%
10
An incident can be associated with more than one cause of incident category.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Overdose Incidents In 2006-07 five of the ten most common medications involved in overdose incidents were analgesics, including four opioid analgesics, two were anti-coagulants and the remainder were antiarrhythmics, parenteral fluids and antibiotics (Table 8).
In 2007-08 four of the ten most common medications involved in overdose incidents were analgesics, including three opioid analgesics, two were anticoagulants, with the remainder being a calcium supplement, a diuretic, an insulin preparation and an antibiotic.
Table 8: Top 10 Medications Involved in Overdose Incidents in WA 2006-07 and 2007-08 11

Rank 2006-07 Number of Incidents (%) 117 Paracetamol (11.5%) Amiodarone 41 (4.0%) hydrochloride Medication Morphine Heparin Metronidazole Codeine phosphate Sodium chloride Oxycodone hydrochloride Fentanyl Enoxaparin sodium 35 (3.4%) 32 (3.1%) 29 (2.8%) 25 (2.5%) 23 (2.3%) 20 (2.0%) 20 (2.0%) 17 (1.7%) Medication class Rank 2007-08 Number of Incidents (%) 114 Paracetamol (11.6%) 40 (4.1%) Heparin Medication Morphine Calcium carbonate Frusemide Codeine phosphate Fentanyl Insulin Enoxaparin sodium Gentamicin 26 (2.6%) 25 (2.5%) 25 (2.5%) 19 (1.9%) 18 (1.8%) 18 (1.8%) 17 (1.7%) 16 (1.6%) Medication class
1 2 3 4 5 6 7 8 9 10
Analgesic Antiarrhythmic agent Opioid analgesic Anticoagulant Antibiotic Opioid analgesic Parenteral fluid Opioid analgesic Opioid analgesic Anticoagulant
1 2 3 4 5 6 7 8 9 10
Analgesic Anticoagulant Opioid analgesic Calcium supplement Diuretic Opioid analgesic Opioid analgesic Insulin preparation Anticoagulant Antibiotic
11
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figures 12a and 12b show the proportion of overdose incidents falling into each of the AIMS Outcome Level categories. In 2006-07 40.7% were associated with no harm to the patient, 57.6% with minor to moderate harm, and 1.7% with significant or severe harm to the patient.
In 2007-08 36.6% of medications overdoses were associated with no harm to the patient, 62.0% with minor to moderate harm, and 1.5% with significant or severe harm to the patient. Figure 12a: Percent of Overdose Incidents by Outcome Level Category 2006-07
1.7%
40.7% 57.6%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 12b: Percent of Overdose Incidents by Outcome Level Category 2007-08
1.5%
36.6%
62.0%
For both 2006-07 and 2007-08 the most common reasons for medicine overdoses were failure to read or misread (54.2% 2006-07 and 50.1% 2007-08) and failure to follow policy or procedure (44.0% 2006-07 and 46.4% 2007-08; Table 9).
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Table 9: Percent of Overdose Incidents by Causes of Overdose Incident Category 2006-07 and 2007-08 12
2006-07 Cause of Incident Proportion of Overdose Incidents Failure to read or 54.2% misread Failure to follow 44.0% policy or procedure Prescription or 23.9% order error Unclear or 10.9% incomplete order Other 9.3% Incorrect 3.0% calculation Dispensing error 1.9% Administered when 1.8% held or ceased New order 1.4% overlooked Patient self 1.2% medicating 2007-08 Cause of Incident Proportion of Overdose Incidents Failure to read or 50.1% misread Failure to follow 46.4% policy or procedure Prescription or 17.4% order error Unclear or 10.5% incomplete order Other 9.5% Incorrect 3.2% calculation Dispensing error 2.8% Patient self 2.0% medicating New order 1.7% overlooked Administered when 1.3% held or ceased
Wrong Medication, Additive or Fluid Incidents The top ten wrong medication, additive or fluid incidents in 2007-08 are shown in Table 10. In 2006-07 three of the ten most-common medications involved in wrong medication incidents were analgesics, including two opioid analgesics, two were antibiotics and three were anti-hypertensives. The remainder were parenteral fluids.
In 2007-08 three of the ten most-common medications involved in wrong medication, additive or fluid incidents were opioid analgesics, two were involved in dopamine regulation, two were bronchodilators and there was one each of insulin preparations, parenteral fluids and anticoagulants.
12
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Table 10: Top 10 Medications Involved in Wrong Medication, Additive or Fluid Incidents in WA 2006-07 and 2007-08 13
Rank 1 2 Medication 2006-07 No. of Incidents 54 (7.8%) 36 (5.2%) 26 (3.8%) 24 (3.5%) 21 (3.0%) 20 (2.9%) 18 (2.6%) 18 (2.6%) 17 (2.5%) 17 (2.5%) Medication class Opioid Analgesic Parenteral fluid Opioid Analgesic Analgesic Antibiotic Antibiotic Antihypertensive Antihypertensive Diuretic/Antihypertensive Parenteral fluid Rank 1 2 Medication Levodopa Benserazide hydrochloride Oxycodone Oxycodone hydrochloride Salbutamol Ipratropium bromide Sodium chloride Warfarin sodium Insulin Morphine sulfate 2007-08 No. of Incidents 74 (9.7%) 73 (9.6%) 41 (5.4%) 34 (4.5%) 25 (3.3%) 22 (2.9%) 21 (2.8%) 19 (2.5%) 19 (2.5%) 18 (2.4%) Medication class Dopamine Precursor Dopa Decarboxylase Inhibitor Opioid Analgesic Opioid Analgesic Bronchodilator Bronchodilator Parenteral Fluid Anticoagulant Insulin Preparation Opioid Analgesic
Oxycodone hydrochloride Sodium chloride Oxycodone Paracetamol Amoxycillin Amoxycillin trihydrate Irbesartan Nifedipine Hydrochlorothiazide Dextrose
3 4 5 6 7 8 9 10
3 4 5 6 7 8 9 10
Figures 13a and 13b show the proportion of wrong medication, additive or fluid incidents falling into each of the AIMS Outcome Level categories.
In 2006-07 49.1% were associated with no harm to the patient, 50.2% with minor to moderate harm, and 0.7% with significant or severe harm to the patient.
In 2007-08 53.7% were associated with no harm to the patient, 45.6% with minor to moderate harm, and 0.7% with significant to severe harm to the patient.
13
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 13a: Percent of Wrong Medication, Additive or Fluid Incidents by Outcome Level Category 2006-07
0.7%
50.2%
49.1%
Figure 13b: Percent of Wrong Medication, Additive or Fluid Incidents by Outcome Level Category 2007-08
0.7%
45.6%
53.7%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 In 2006-07 the four most common causes of these incidents were failure to read or misread (58.1% of all overdose incidents), failure to follow policy or procedure (43.3%), prescription or order error (22.2%) and previous known adverse reaction (10.3% Table 11).
In 2007-08 the four most common causes of these incidents were failure to read or misread (57.2% of all wrong medication, additive or fluid incidents), failure to follow policy or procedure (42.0%), other (8.7%) and prescription or order error (8.0% Table 11). Table 11: Percent of Wrong Medication, Additive or Fluid Incidents by Causes of Wrong Medication, Additive or Fluid Incident Category 2006-07 and 2007-08 14
2006-07 Cause of Incident Proportion of Wrong Medication, Additive or Fluid Incidents Failure to read or misread Failure to follow policy or procedure Prescription or order error Previous known adverse reaction Unclear or incomplete order Other Dispensing error Medication not available Administered when held or ceased New order overlooked Patient self medication Incorrect calculation
14
2007-08 Cause of Incident Proportion of Wrong Medication, Additive or Fluid Incidents Failure to read or misread Failure to follow policy or procedure Other Prescription or order error Unclear or incomplete order Dispensing error Previous known adverse reaction Patient self medicating Medication not available Administered when held or ceased New order overlooked 57.2% 42.0% 8.7% 8.0% 5.5% 4.7% 3.9% 1.8% 1.7% 0.9% 0.9% -
58.1% 43.3% 22.2% 10.3% 7.0% 5.5% 2.8% 1.9% 1.3% 0.9% 0.9% 0.9%
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Time of Medication Incidents
In Figures 14a and 14b peak periods for medication incidents were observed between 0800-0859hrs (15.4% 2006-07 and 15.9% 2007-08) and to a lesser extent between 2000-2059hrs (8.4% 2006-07 and 9.9% 2007-08). Figure 14a: Medication Incidents by Time of Day 2006-07
1,000 900 800 Number of medication incidents 700 600 500 400 300 200 100 0
* Time was not recorded for 19.2% of data in 2006-07.
Figure 14b: Medication Incidents by Time of Day 2007-08

1,200
Number of Medication Incidents
* Time was not recorded for 17.3% of data in 2007-08.
00 :0 0 -0 01 0: :0 59 0 -0 02 1: :0 59 0 -0 03 2: :0 59 0 -0 04 3: :0 59 0 -0 05 4: :0 59 0 -0 06 5: :0 59 0 -0 07 6: :0 59 0 -0 08 7: 59 :0 0 -0 09 8: :0 59 0 -0 10 9: :0 59 0 -1 11 0: :0 59 0 -1 12 1: :0 59 0 -1 13 2: :0 59 0 -1 14 3: :0 59 0 -1 15 4: :0 59 0 -1 16 5: 59 :0 0 -1 17 6: :0 59 0 -1 18 7: :0 59 0 -1 19 8: :0 59 0 -1 20 9: :0 59 0 -2 21 0: :0 59 0 -2 22 1: :0 59 0 -2 23 2: :0 59 0 -2 3: 59
Time
1,000
800
600
400
200
0
59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 59 0: 0 1: 0 2: 0 3: 0 4: 0 5: 0 6: 0 7: 0 8: 0 9: 1 0: 1 1: 1 2: 1 3: 1 4: 1 5: 1 6: 1 7: 1 8: 1 9: 2 0: 2 1: 2 2: 2 3: -0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 :0 1:0 2:0 3:0 4:0 5:0 6:0 7:0 8:0 9:0 0:0 1:0 2:0 3:0 4:0 5:0 6:0 7:0 8:0 9:0 0:0 1:0 2:0 3:0 0 0 00 0 0 0 0 1 0 0 1 0 1 1 1 1 1 1 1 1 2 2 2 2
Time
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Medications Involved in Incidents In 2006-07 the top three medications involved in all types of medication incidents (Table 12) were paracetamol (5.4% of all medication incidents), morphine (2.9%) and oxycodone hydrochloride (2.8%).
In 2007-08 the top three medications involved in all Medication incidents (Table 12) were paracetamol (6.3% of all Medication incidents), heparin (2.8%) and insulin (2.2%).
Table 12: Top 10 Medications Involved in Medication Incidents in WA 2006-07 and 2007-08 15 2006-07 Medication No. of Incidents 303 Paracetamol (5.4%) 163 Morphine (2.9%) Oxycodone 156 hydrochloride (2.8%) 146 Frusemide (2.6%) 131 Heparin (2.4%) Warfarin 122 sodium (2.2%) Potassium 111 chloride (2.0%) Sodium 107 chloride (1.9%) Gentamicin Fentanyl 99 (1.8%) 89 (1.6%) 2007-08 Medication No. of Incidents 402 Paracetamol (6.3%) 181 Heparin (2.8%) 143 Insulin (2.2%) 142 Oxycodone (2.2%) Oxycodone 142 hydrochloride (2.2%) Warfarin 136 sodium (2.1%) 132 Morphine (2.1%) 122 Frusemide (1.9%) 116 Levodopa (1.8%) Sodium 110 chloride (1.7%)
Rank 1 2 3 4 5 6 7 8 9 10
Medication class
Rank 1 2 3 4 5 6 7 8 9 10
Medication class
Analgesic Opioid analgesic Opioid analgesic Diuretic Anticoagulant Anticoagulant Electrolyte Parenteral fluid Antibiotic Opioid analgesic
Analgesic Anticoagulant Insulin Preparation Opioid Analgesic Opioid Analgesic Anticoagulant Opioid Analgesic Diuretic Dopamine Precursor Parenteral Fluid
15
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Findings revealed that patients aged between 0-14 years had the highest Medication incident rate. The top ten medications involved in all types of Medication incidents are found in Table 13.
In 2006-07 paracetamol (8.0% of all medication incidents), metronidazole (6.6%) and gentamicin (5.5%) were the three most frequently reported medication incidents. While in 2007-08 paracetamol (6.8% of all Medication incidents for this age group), gentamicin (4.8%) and sodium chloride (4.5%) formulated the most frequent medication incidents.
Table 13: Top 10 Medications Involved in all Medication Incidents for the 0-14 Age Group in WA 2006-07 and 2007-08 16 Rank 1 2 3 4 5 6 7 8 9 10 2006-07 Medication No. of Incidents Paracetamol 48 (8.0%) Metronidazole 40 (6.6%) Gentamicin Morphine Hepatitis B vaccine Sodium chloride Flucloxacillin Amoxycillin Vancomycin hydrochloride Ibuprofen 33 (5.5%) 30 (5.0%) 22 (3.7%) 22 (3.7%) 18 (3.0%) 16 (2.7%) 14 (2.3%) 13 (2.2%) Medicatio Rank n class Analgesic 1 Antibiotic 2 Antibiotic Opioid analgesic Vaccine Parenteral fluid Antibiotic Antibiotic Antibiotic
Antiinflammatory
3 4 5 6 7 8 9 10
2007-08 No. of Incidents Paracetamol 46 (6.8%) Gentamicin 32 (4.8%) Sodium 30 (4.5%) chloride Potassium 26 (3.9%) clavulanate Medication Amoxycillin Amoxycillin trihydrate Topiramate Vancomycin hydrochloride Metronidazole Ticarcillin sodium 21 (3.1%) 19 (2.8%) 18 (2.7%) 18 (2.7%) 16 (2.4%) 16 (2.4%)
Medication class
Analgesic Antibiotic Parenteral Fluid Antibiotic Antibiotic Antibiotic Anticonvulsant Antibiotic Antibiotic Antibiotic
16
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Patient Demographics The number of reported Medication incidents increased with age of patients (Figures 15a and 15b). However, the highest rate of Medication incidents occurred in the 5-9 year age group with 6.3 incidents (2006-07 and 2007-08) per 1,000 bed days, followed by the 10-14 year age group with 6.2 (2006-07) and 5.8 (2007-08) Medication incidents per 1,000 bed days. The 0-4 year age group displayed the third highest rate in 2006-07 and the fourth highest rate in 2007-08 with 4.6 and 5.2 Medication incidents per 1,000 bed days respectively.
Figure 15a: Number and Rate of Medication Incidents by Age Group 2006-07
800 7
700
6 Rate of incidents per 1,000 bed days
Number of medication incidents
600 5 500 4 400 3 300 2 200 1
100
0
ye ar s ye 10 a to rs 14 ye 15 ar to s 19 ye 20 a to rs 24 ye 25 a to rs 29 ye 30 ar to s 34 ye 35 a to rs 39 ye 40 ar to s 44 ye 45 a to rs 49 ye 50 ar to s 54 ye 55 a to rs 59 ye 60 a to rs 64 ye 65 ar to s 69 ye 70 a to rs 74 ye 75 ar to s 79 ye 80 a to rs 84 ye 85 ar to s 89 ye ar s
to 0
05
to
09
Age Group Number of medication incidents Rate of Incidents per 1,000 Bed days
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 15b: Number and Rate of Medication Incidents by Age Group 2007-08
1,200 Number of Medication Incidents 1,000 800 600 3 400 200 0 2 1 0 7 6 5 4 Rate of Medication Incidents per 1,000 Bed Days
Contributing Factors In both 2006-07 and 2007-08 approximately 93% of contributing factors for Medication incidents were attributed to staff-related factors. The four most common staff contributing factors were failure to follow policy or procedure (45.4% 2006-07 and 47.1% 2007-08 of all Medication incidents), misread or did not read documentation (45.3% 2006-07 and 40.9% 2007-08), inadequate knowledge or inexperience (19.2% 2006-07 and 17.1% 2007-08) and communication problem (15.2% 2006-07 and 14.0% 2007-08 Table 14).
04 y 5- ear 9 s 10 ye -1 ar s 4 15 ye -1 ar s 9 20 ye -2 ar 4 s 25 ye -2 ar s 9 30 ye -3 ar 4 s 35 ye -3 ar s 9 40 ye -4 ar s 4 45 ye -4 ar 9 s 50 ye -5 ar s 4 55 ye -5 ar s 60 9 ye -6 ar 4 s 65 ye -6 ar s 70 9 ye -7 ar 4 s 75 ye -7 ar s 9 80 ye -8 ar s 4 85 ye a + rs ye ar s
Age Group Number of Medication Incidents Rate of Medication Incidents per 1,000 Bed Days
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Table 14: Number and Percent of Medication Incidents by Staff Contributing Factor Category 2006-07 and 2007-08 17
Contributing Factor Failure to follow policy or procedure Misread or did not read documentation Inadequate knowledge or inexperience Communication problem Other Poor teamwork or supervision Distraction or inattention Multiple staff or poor continuity Failure to follow advice or instructions Fatigue or stress or unwell Insufficient or inadequate staff Pressure to proceed Staff did not attend when required Medication not reviewed No PRN medications ordered PRN medications not used 2006-07 2007-08 Number of Proportion Number of Proportion Contributing Medication of all Medication of all Incidents Medication Factor Incidents Medication Incidents Incidents Failure to follow 2,525 45.4% policy or 3,021 47.1% procedure Misread or did not 2,518 45.3% 2,625 40.9% read documentation Inadequate 1,067 19.2% knowledge or 1,099 17.1% inexperience Communication 844 15.2% 896 14.0% problem 760 507 437 412 218 13.7% 9.1% 7.9% 7.4% 3.9% Other Poor teamwork or supervision Distraction or inattention Fatigue or stress or unwell Insufficient or inadequate staff Failure to follow advice or instructions Multiple staff or poor continuity Staff did not attend when required Pressure to proceed Medication not reviewed No PRN medications ordered PRN medications not used 749 557 390 259 200 11.7% 8.7% 6.1% 4.0% 3.1%
207 150 44
3.7% 2.7% 0.8%
167 159 29
2.6% 2.5% 0.5%
24 23 4 3
0.4% 0.4% 0.1% 0.1%
28 11 4 4
0.4% 0.2% 0.1% 0.1%
17
An incident can be associated with more than one contributing factor.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 3.3.3 Discussion Medication incidents are not only a significant clinical problem in WA, but also interstate26-27, 30 and internationally.47-48 As reflected in other health systems, Medication incidents involving omissions, incorrect doses (in particular overdoses) and incorrect medications, represent the majority of Medication incidents. The prescribing, dispensing and administering of medications in the modern hospital environment is an issue not limited to local conditions.
The number of medication incidents notified to AIMS in 2007-08 increased by 13.2% compared to 2006-07. This increase may be due to an overall increase in the reporting of medication incidents by health services, or reflective of a backlog of data entry and classification of incidents. However, the rate of reporting was shown to decrease slightly from 4.1 incidents per 1,000 bed days in 2006-07 to 3.7 incidents per 1,000 bed days in 2007-08.
The three most commonly reported types of Medication incident were omission incidents, overdose incidents and wrong medication, additive or fluid incidents. In 2006-07, Warfarin (anti-coagulant) was the most commonly reported medication involved in omission medication incidents (82 incidents, 4.3%) with paracetamol (analgesic) the most common in 2007-08 (107 incidents, 5.4%).
While Paracetamol (analgesic) was the most commonly reported medication involved in overdose medication incidents in both 2006-07 (117 incidents, 11.5%) and 2007-08 (114 incidents, 11.6%).
Oxycodone (opioid analgesic) was the most commonly reported medication involved in wrong medication, additive, fluid incidents in 2006-07 (80 incidents, 11.6%) and levodopa (dopamine precursor) was the most common in 2007-08 (74 incidents, 9.7%).
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 The increased vulnerability of younger patients to Medication incidents reported in the UK48 and in North46 and South47 America was reflected in the AIMS data in 2006-07 and 2007-08. The medication most commonly associated with WA Medication incidents involving the 0-14 year age group was paracetamol, an overdose of which can lead to severe side-effects including hepato-toxicity and nephrotoxicity.49
The prescribing and administering of medications is often a complex process requiring considerable attentiveness and the ability to calculate concentrations and dilutions.37,
41, 50
Consequently, the majority of Medication incidents reported by staff included as
their causes, a failure to properly read or the misreading of a prescription, the failure to follow medication related policies and procedures or errors in medication documentation such as prescription or order errors or unclear / incomplete orders. Other causes and contributing factors included inadequate knowledge and communication problems. A recent study in a Western Australian tertiary hospital51 highlighted the importance of staff and environmental factors in Medication incidents. The authors suggested several strategies to reduce medication errors including: Training staff to recognise error-prone clinical situations Greater emphasis on safe prescribing practices in training Increased access to medication information at the point of prescribing More attention to communication barriers.
The recommendations made in the report by the hospital51 mirror those recommendations found in the Medication incidents notified to the AIMS database in 2006-07 and 2007-08. Clifford Hughes37 stated that to decrease the number of Medication incidents in the hospital setting Practitioners must be able to concentrate, without distraction, on the patients for whom they are prescribing. They must have adequate information on the indications for the prescription, potential complications, contraindications and drug interactions in the prescribed medications.
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3.3.4 Key Messages Since the inception of AIMS, Medication incidents have consistently been the second most notified event Consistent with the literature, over half of all reported Medication incidents resulted in no harm to the patient, with missed doses and overdoses representing almost fifty percent of Medication incident types Also consistent with the literature, is that policy and procedure issues regarding prescribing and administration of medications are a significant contributing factor Health services should ensure compliance with the WA Department of Health Operational Directives on medication safety,52-54 the National Inpatient Medication Chart Guidelines55 and the Pharmaceutical Review Policy.56
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3.4 Behaviour Incidents

3.4.1 Introduction Behaviour incidents refer to any event involving behavioural issues such as verbal and / or physical abuse or aggression, non-compliance, absconding, self harm and suicide. Violent and aggressive behaviour by patients towards staff and other patients in hospitals has been reported in the media57-59 and is a growing problem in Australia.6067
This problem is not confined to emergency rooms60-63 and mental health facilities60but also occurs in the general hospital,61, 64 remote care,66 maternity, disability
62, 65
services and aged care settings.60
Behavioural incidents in healthcare have been associated with mental health disorders, dementia, drug and alcohol intoxication, and environmental factors such as increased hospital waiting times.68-69 National and international studies of aggressive behaviour in hospitals have highlighted the significant effects these incidents have on both staff and patients, including psychological and physical trauma.68, 70-72
3.4.2 Results Behaviour Incidents 2006-07 and 2007-08 Between 1 July 2007 and 30 June 2008 there were 3,844 Behaviour incidents notified into AIMS, representing approximately one seventh (14.1%) of all notifications. There were 1000 more Behaviour incidents notified in 2007-08 compared to 2006-07, an increase of 26%.
Trends in Behaviour Incidents 2001-08 Between 2001-02 and 2007-08, Behaviour incidents have consistently ranked as the third or fourth-most notified incident type, with an average of 2,664 incidents per year. There has been a small upward trend in the number of Behaviour incidents since 2001-02 (Table 15), with a greater increase seen between 2006-07 and 2007-08. The rate of Behaviour incidents from 2001-02 to 2007-08 ranged from 0.8 to 2.5 incidents per 1,000 bed days.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Table 15: Number and Rate of Behaviour Incidents Notified Per Year 2001-08 18
2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 Number of Behaviour Incidents 1,173 2,438 2,591 2,638 2,834 2,884 3,844 Number of Bed Days 1,393,388 1,477,925 1,446,603 1,513,179 1,491,433 1,494,006 1,548,462 Rate/1,000 Bed Days 0.8 1.6 1.8 1.7 1.9 1.9 2.5
The proportion of all clinical incidents classified as Behaviour incidents ranged from 10.9% to 14.1% from 2001-08.
Outcome of Behaviour Incidents The majority of Behaviour incidents (71.0% 2006-07 and 67.7% 2007-08) were associated with minor to moderate harm to the patient requiring, review by a doctor and further treatment such as extra monitoring, specialling, medication or security attendance (Figure 16a and 16b). In addition, 11.8% (2006-07) and 17.1% (2007-08) of Behaviour incidents were associated with significant to severe harm (e.g. transfer and admission to another hospital, closed ward management, placement on forms under the Mental Health Act, seclusion, or permanent disability or death). Of all incidents, Behaviour incidents had the greatest proportion of significant to severe outcomes. In 2006-07 twelve Behaviour incidents were associated with patient death compared with thirteen deaths in 2007-08.
Implementation of AIMS was commenced in October 2001, therefore data for 2001-02 is not for a full year.
18
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Figure 16a: Percent of Behaviour Incidents by Outcome Level Category 2006-07

11.8% 16.6%
71.0%
Figure 16b: Percent of Behaviour Incidents by Outcome Level Category
2007-08
14.9% 17.1%
67.7%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Type of Behaviour Incident Behaviour incidents can be classified into ten subcategories. The number of incidents notified during 2006-07 and 2007-08 for each subcategory is displayed in Figures 17a and 17b.
The three most common types of Behaviour incident included: Physical abuse, aggression or assault (41.3% of all behaviour incidents in 2006-07 and 43.9% of all Behaviour incidents in 2007-08) Verbal abuse or aggression (31.4% 2006-07 and 36.3% 2007-08) Absconding (19.8% 2006-07 and 20.9% 2007-08).
Figure 17a: Number of Behaviour Incidents by Behaviour Subcategory Type 2006-07 19

1,400 Number of Behaviour Incidents 41.3% 1,200 1,000 800 600 400 200 0
la bu se ,a gg re ss Ve io rb n or al ab as us sa ul e t or ag gr es sio n Ab sc on In di te ng nd ed se lf ha rm N on Su -c om In ic ap id pl al pr ia op nc be e ri a ha te vi ou be ro ha ra vio In tte ap ur m pr pt op e ri a d su te ic se ide xu al be ha vi ou Se r lf di sc ha rg O e th er Be ha vi ou r
31.4%
19.8% 11.3% 10.3%
9.6% 4.1% 1.5% 1.4% 0.8%
19
A behaviour incident can be labelled with more than one incident type.
Ph ys ica
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Figure 17b: Number of Behaviour Incidents by Behaviour Subcategory 2007-08 20

1,800 1,600 1,400 1,200 1,000 800 600 400 200 0
12.4% 9.6% 9.1% 2.9% 1.6% 1.5% 0.9% 20.9% 43.9% 36.3%
Number of Behaviour Incidents

20
Physical Abuse, Aggression or Assault Figures 18a and 18b show the Outcome Levels for the physical abuse, aggression or assault clinical incidents reported to AIMS in 2006-07 and 2007-08.
In 2006-07 70.9% and in 2007-08 63.0% of incidents were classified as having a minor or moderate outcome for the patient (Outcome Level 4 to 6) where a doctor reviewed the affected patient and minor diagnostic investigations were required.
In 2006-07 13.1% and in 2007-08 9.2% were associated with no patient harm, while 16.0% (2006-07) and 27.8% (2007-08) were associated with a significant to severe outcome (Outcome Level 7 to 8) requiring, for example, an increased length of stay, secure ward management or seclusion. There were no patient deaths in 2006-07 and one patient death associated with these incidents in 2007-08.
A behaviour incident can be labelled with more than one incident type.
ag gr Ve es sio rb al n ab or us as e sa or ul t ag gr es si on Ab sc on No di nIn ng co ap m Su pr pl op ici ia da r ia nc lb te e eh b In eh av te av nd io io ur ed ur or In s ap e at l fh te pr m ar op pt m r ia ed te su se ici xu de al be ha O th vio er ur Be ha vio Se ur lf di sc ha rg e
Ph ys i
ca l
ab us e,
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 18a: Percent of Physical Abuse, Aggression or Assault Incidents by Outcome Level Category 2006-07
13.1% 16.0%
70.9%
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Figure 18b: Percent of Physical Aggression, Abuse or Assault Incidents by Outcome Level Category 2007-08
9.2%
27.8%
63.0%
Figures 19a and 19b show the times of day during which physical abuse, aggression or assault incidents were recorded.
In 2006-07 the majority of these incidents (76.0%) occurred between 0800hrs and 22.59hrs with a peak between 1700hrs and 1859hrs (13.3% of incidents). In 2007-08 the majority of these incidents (67.1%) occurred between 0800hrs and 2059hrs with a peak between 1600hrs and 1659hrs (7.8%).
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Number of Physical Aggression, Abuse or Assault Incidents
Number of Incidents
00 :0 0 -0
100
110
120
130
10
20
30
40
50
60
70
80
90
10
20
30
40
50
60
70
80
90
02 :0 0 -0 2: 59 4: 59 6: 59 8: 59 0: 59 2: 59 4: 59 16 :0 0 18 :0 0 20 :0 0 22 :0 0 -1 -1 -2 6: 59 8: 59 0: 59 -2 N o 2: 59 Ti m -0 -0 -0 -1 04 :0 0 06 :0 0 08 :0 0 10 :0 0 12 :0 0 -1 -1 14 :0 0
* A small percentage of these incidents (3.5%) did not have a time recorded.
0: 59 e
Figure 19b: Number of Physical Abuse, Aggression or Assault Incidents by Time of Day 2007-08
Figure 19a: Number of Physical Abuse, Aggression or Assault Incidents by Time of Day for 2006-07
00 :0 0 01 - 0 :0 0: 5 0 02 - 0 9 :0 1:5 0 9 03 - 0 :0 2:5 0 9 04 - 0 :0 3: 5 0 05 - 0 9 :0 4:5 0 06 - 0 9 :0 5: 5 0 07 - 0 9 :0 6:5 0 08 - 0 9 :0 7: 5 0 09 - 0 9 :0 8:5 0 9 10 - 0 :0 9:5 0 9 11 - 1 :0 0: 5 0 12 - 1 9 :0 1:5 0 13 - 1 9 :0 2: 5 0 14 - 1 9 :0 3:5 0 9 15 - 1 :0 4:5 0 16 - 1 9 :0 5: 5 0 17 - 1 9 :0 6:5 0 18 - 1 9 :0 7: 5 0 19 - 1 9 :0 8:5 0 20 - 1 9 :0 9: 5 0 21 - 2 9 :0 0:5 0 9 22 - 2 :0 1:5 0 23 - 2 9 :0 2: 5 0 -2 9 3: 59
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figures 20a and 20b show the days of the week for all reported physical abuse, aggression or assault incidents with very little difference shown between particular days of the week. Figure 20a: Number of Physical Abuse, Aggression or Assault Incidents by Days of Week for 2006-07
200 180 160 140 120 100 80 60 40 20 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Figure 20b: Number of Physical Abuse, Aggression or Assault Incidents by Day of the Week 2007-08
Number of Physical Aggression, Abuse or Assault Incidents 250
Number of Incidents
200
150
100
50
0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Verbal Abuse or Aggression Figures 21a and 21b show the Outcome Levels for the verbal abuse or aggression clinical incidents. In 2006-07 68.3% were classified as having a moderate outcome (outcome level 4 to 6) for the patient where a doctor reviewed the affected patient and minor diagnostic investigations were required. Twenty two point nine of the incidents were associated with no patient harm, while 8.8% with a significant outcome (outcome level 7) requiring, for example, an increased length of stay, secure ward management or seclusion. In 2007-08 69.3% were classified as having a minor to moderate outcome (Outcome Level 4 to 6) for the patient, 18.1% of the incidents were associated with no patient harm, while 12.5% were associated with a significant to severe outcome (Outcome Level 7 to 8).
Figure 21a: Percent of Verbal Abuse or Aggression Incidents by Outcome Level Category 2006-07
8.8% 22.9%
68.3%
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 21b: Percent of Verbal Abuse or Aggression Incidents by Outcome Level Category 2007-08
12.5%
18.1%
69.3%
Figures 22a and 22b show the times of day during which verbal abuse or aggression incidents were recorded.
In 2006-07 the majority of these incidents (69.5%) occurred between 0900hrs and 2259hrs with a peak between 1100hrs and 1159hrs (6.9% of incidents). A smaller peak occurred between 0300hrs to 0459hrs (8.9%).
In 2007-08 the graph (Figure 22b) shows a peak in incidents occurring between 10am and 10:59am.
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Number of Verbal Abuse or Aggression Incidents
Number of Incidents
00 :0 0
10 15 20 25 30 0 5
10
15
20
25
30
35
40
35
02 :0 0 04 :0 0 06 :0 0 08 :0 0 10 :0 0 12 :0 0 14 :0 0 16 :0 0 18 :0 0 20 :0 0 22 :0 0 -1 4: 59 -1 6: 59 -1 8: 59 -2 0: 59 -2 2: 59 No Ti m e -1 2: 59 -1 0: 59 -0 8: 59 -0 6: 59 -0 4: 59 -0 2: 59
Figure 22a: Number of Verbal Abuse or Aggression Incidents by Time of Day for 2006-07
Figure 22b: Number of Verbal Abuse or Aggression Incidents by Time of Day for 2007-08
-0 0: 59
00 :0 0 01 - 0 :0 0 : 0 02 - 0 5 9 :0 1 : 0 03 - 0 5 9 :0 2 : 0 04 - 0 5 9 :0 3 : 0 05 - 0 5 9 :0 4 : 06 0 - 5 9 :0 05 0 : 07 - 0 5 9 :0 6 : 0 08 - 0 5 9 :0 7 : 0 09 - 0 5 9 :0 8 : 0 10 - 0 5 9 :0 9 : 0 11 - 1 5 9 :0 0 : 0 12 - 1 5 9 :0 1 : 0 13 - 5 9 :0 12 0 : 14 - 1 5 9 :0 3 : 0 15 - 1 5 9 :0 4 : 0 16 - 1 5 9 :0 5 : 0 17 - 1 5 9 :0 6 : 0 18 - 1 5 9 :0 7 : 19 0 - 5 9 :0 18 0 : 20 - 1 5 9 :0 9 : 0 21 - 2 5 9 :0 0 : 0 22 - 2 5 9 :0 1 : 0 23 - 2 5 9 :0 2 : 0 5 -2 9 3 No :5 9 Ti m e
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figures 23a and 23b show the days of the week for all reported verbal abuse or aggression incidents. In 2006-07 there is very little difference between any particular day of the week however the 2007-08 graph shows a peak on Thursday and Friday (17.3% and 17.7% respectively). Figure 23a: Number of Verbal Abuse or Aggression Incidents by Days of the Week 2006-07
80 70 60 Number of Incidents 50 40 30 20 10 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Figure 23b: Number of Verbal Abuse or Aggression Incidents by Day of Week 2007-08
90 Number of Verbal Abuse or Aggression Incidents 80 70 60 50 40 30 20 10 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Absconding In 2006-07 70.7% were classified as having a moderate outcome (outcome level 4 to 6) for the patient where a doctor reviewed the affected patient and minor diagnostic investigations were required (Figure 24a). Twenty one point six percent were associated with no patient harm, while 4.6% were associated with a significant or severe patient outcome (outcome level 7 or 8) requiring, for example, an increased length of stay, secure ward management or seclusion (Figure 24b).
In 2007-08 79.8% were classified as having a minor to moderate outcome (Outcome Level 4 to 6) for the patient, 11.4% were associated with no patient harm, while 6.9% were associated with a significant or severe patient outcome (Outcome Level 7 to 8). There was one patient death associated with this category of incident in 2006-07 and no deaths in 2007-08. Figure 24a: Percent of Absconding Incidents by Outcome Level Category 2006-07
4.6% 21.6%
70.7%
* A small percentage of these incidents (3.1%) were missing.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 24b: Percent of Absconding Incidents by Outcome Level Category 2007-08
6.9% 11.4%
79.8%
Figures 25a and 25b show the times of day during which absconding incidents were recorded.
In 2006-07 the majority of these incidents (66.0%) occurred between 0900hrs and 2159hrs with a peak between 1300hrs and 1359hrs (7.7% of incidents).
In 2007-08 the majority of these incidents (60.4%) occurred between 1000hrs and 2159hrs with a peak between 1600hrs and 1659hrs (8.2% of incidents).
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Number of Absconding Incidents
Number of Incidents
00 :0 0
10
20
30
40
50
60
10
15
20
25
30
35
40
45
02 :0 0 :0 0 :0 0 :0 0 :0 0 :0 0 :0 0 :0 0 18 20 22 :0 0 :0 0 :0 0 -1 2: 59 -1 4: 59 16 -1 6: 59 -1 8: 59 -2 0: 59 -2 2: 59 No Ti m e -1 0: 59 -0 8: 59 -0 6: 59 -0 4: 59 -0 2: 59 04 06 08 10 12 14

-0 0: 59
Figure 25b: Number of Absconding Incidents by Time of Day 2007-08
Figure 25a: Number of Absconding Incidents by Time of Day 2006-07
00 :0 0 01 - 0 :0 0: 5 0 02 - 0 9 :0 1: 59 0 03 - 0 :0 2: 0 5 04 - 0 9 :0 3: 5 0 05 - 0 9 :0 4: 0 5 06 - 0 9 :0 5: 5 0 07 - 0 9 :0 6: 5 0 08 - 0 9 :0 7: 0 5 09 - 0 9 :0 8: 5 0 10 - 0 9 :0 9: 0 5 11 - 1 9 :0 0: 5 0 12 - 1 9 :0 1: 59 0 13 - 1 :0 2: 0 5 14 - 1 9 :0 3: 5 0 15 - 1 9 :0 4: 0 59 16 - 1 :0 5: 5 0 17 - 1 9 :0 6: 5 0 18 - 1 9 :0 7: 0 5 19 - 1 9 :0 8: 5 0 20 - 1 9 :0 9: 0 5 21 - 2 9 :0 0: 5 0 22 - 2 9 :0 1: 5 0 23 - 2 9 :0 2: 0 5 -2 9 3: N 59 o Ti m e
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 In the 2006-07 graph (Figure 26a) the end of the week (Thursday to Sunday) showed an increased number of incidents compared to the start of the week (Monday to Wednesday). For 2007-08 (Figure 26b) very little difference is show between particular days of the week. Figure 26a: Number of Absconding Incidents by Days of the Week 2006-07
100 90 80 Number of Incidents 70 60 50 40 30 20 10 0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Figure 26b: Number of Absconding Incidents by Day of Week 2007-08
120
100 Number of Absconding Incidents
80
60
40
20
0 Monday Tuesday Wednesday Thursday Friday Saturday Sunday
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Behaviour Incidents in WA Mental Health Facilities Mental health facilities notified a significant proportion of the Behaviour incidents to AIMS (1,441 or 38.7% of Statewide behaviour incidents in 2006-07 and 1,697 or 44.2% of Statewide Behaviour incidents in 2007-08).
Figures 27a and 27b show the Behaviour incident types for WA mental health facilities. Figure 27a: Percent of Behaviour Incidents by Behaviour Incident Type in WA Mental Health Facilities 2006-07 21
60%
50.9%
50%
40%
30%
23.5%
20%
15.3%
10%
8.1%
8.0%
7.7%
7.4% 2.6% 0.4% 0.4%
0%
Su nc ic e id al be A ha bs vi co ou nd ro in g ra tte In m ap pt pr ed op su ri a ic te id e se xu al be ha vi ou r O th er Be ha vi ou r Se lf di sc ha rg e or as sa ul t se lf ha rm es sio n on -c om pl ia or ag gr be ha te vio ur
si on
ed
In ap pr op ri a
In te nd
ab us e, ag gr es
21
A Behaviour incident can be labelled with more than one incident type.
Ph ys ic al
Ve rb al a
bu se
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 27b: Percent of Behaviour Incidents by Behaviour Incident Type in WA Mental Health Facilities 2007-08 22
Percentage of Behaviour Incidents
60% 50% 40% 30% 20% 10% 0%

ag gr es si rb on al or ab as us sa e or ul t ag g In r e te ss nd io ed n se l f No ha nrm In co ap m pr S p op lia ui cid nc r ia al e te be be ha ha vi vi ou ou Ab ro r s In r c at ap on te pr di m op ng pt r ia ed te su se ic xu id e al be h av O th io er ur B eh av Se io ur lf di sc ha rg e Ve
23.3% 16.2% 12.4% 9.1% 7.4% 4.2% 2.6% 0.8% 49.1%
0.0%
The three most common types of behaviour incidents in WA mental health facilities in 2006-07 and 2007-08 included: Physical abuse, aggression or assault (50.9% 2006-07 and 49.1% 2007-08 of all behaviour incidents notified by WA mental health institutions) Intended self harm (23.5% 2006-07 and 16.2% 2007-08) Verbal abuse or aggression (15.3% 2006-07 and 23.3% 2007-08).
Behaviour Incidents in WA Emergency Care Facilities Emergency care facilities also notified a significant proportion of Behaviour incidents to AIMS in 2006-07 and 2007-08. Overall, these facilities notified 1,063 behaviour incidents to AIMS (28.6% of Statewide behaviour incidents) in 2006-07 and 1124 Behaviour incidents (29.4% of Statewide Behaviour incidents) in 2007-08. Figures 28a and 28b show the Behaviour incident types for WA emergency care facilities.
22
A Behaviour incident can be labelled with more than one incident type.
Ph
ys i
ca l
ab u
se ,
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 28a: Percent of Behaviour Incidents by Behaviour Incident Type in WA Emergency Care Facilities (2006-07) 23
70% 61.7% 60% Number of Behaviour Incidents
50%
40% 33.7% 29.9% 30%
20% 8.3%
10%
6.8% 3.8% 2.5% 2.0% 0.7% 0.4%
0%
ng N on -c om In pl ap ia nc pr e op r ia te be ha vi In ou te r nd ed S s el ui fh ci da ar lb m eh S av el fd io ur is ch or ar at ge te m pt ed su ic id e O In th ap e rB pr op eh r ia av te io ur se xu al be ha vi ou r or ag gr ag es gr si on es si on or as sa ul t A bs co nd i
V er ba la
Figure 28b: Percent of Behaviour Incidents by Behaviour Incident Type in WA Emergency Care Facilities 2007-08 24
Percentage of Behaviour Incidents 70%
59.9%
hy si ca l
ab us e,
bu se
60% 50% 40% 30% 20% 10% 0%

7.3% 5.5% 4.1% 2.7% 2.0% 1.3% 0.4% 38.1% 36.8%
23 24
A Behaviour incident can be labelled with more than one incident type. A Behaviour incident can be labelled with more than one incident type.
on Ab ag sc gr on es di sio ng n or as sa No ul t nco In m ap pl pr ia op nc r ia e te be ha vi O ou Su th er r ici Be da lb h In av eh te io nd av ur ed io ur s el or fh at ar te m m pt ed su In ici ap de S pr e op lf di r ia sc te ha se rg xu e al be ha vio ur
Ve rb al a
bu se
or Ph ys ica l
ab us e,
ag gr es si
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 The three most common types of Behaviour incidents in WA emergency care facilities included: Verbal abuse or aggression (61.7% 2006-07 and 59.9% 2007-08 of all Behaviour incidents notified by WA emergency care facilities) Absconding (29.9% 2006-07 and 38.1% 2007-08) Physical abuse, aggression or assault (33.7% 2006-07 and 36.8% 2007-08).
Contributing Factors The majority (89.0% 2006-07 and 90.7% 2007-08) of factors contributing to Behaviour incidents related to the patient. Figures 29a and 29b show the patient contributing factors for all Behaviour incidents that were notified during 2006-07 and 2007-08. Figure 29a: Number and Percent of Behaviour Incidents by Type of Patient Contributing Factor 2006-07 25
1600 Number of behaviour incidents 1400 1200 1000 800 600 400 200 0
re la C te od M or bi A di lc oh tie ol s or D e Fa dr C m ug ilu on en re fu tia in si to to o xi n fo ca or llo tio w di n so ad rie v ic La n e ta ng or tio ua in n ge st r uc or tio sp ns ee P ch hy ba si V ca rr er ie li y rs A m ill ffe ,f pa ra ct irm il, ed en de by ts bi m lit at ed ed ic at or io ge n C ne V ra A l d or et TI er A io ra U tio ns D n is te tra ad ct y io on n fe or et in at te nt io n
51.9%
18.4% 13.3% 11.8% 10.1% 7.5% 1.8% 1.6% 1.1% 0.8% 0.3% 0.2% 0.0%
25
A Behaviour incident can be associated with more than patient contributing factor.
M en ta lh ea lth
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 29b: Number and Percent of Behaviour Incidents by Type of Patient Contributing Factor 2007-08 26
2,500 Number of Behaviour Incidents
55.9%
2,000 1,500 1,000

16.4% 13.2% 13.2%
500 0
11.0%
9.3% 1.2% 1.2% 1.2% 0.9% 0.3% 0.3%
In 2006-07 the four patient contributing factors most commonly associated with behaviour incidents (excluding the other contributing factor category) were: Mental health related (51.9% of all behaviour incidents have this contributing factor) Patient co-morbidities (18.4%) Dementia (13.3%) Alcohol or drug intoxication (11.8%).
26
A Behaviour incident can be associated with more than patient contributing factor.
M en ta lh ea lth Pa re t ie la nt te d co -m or bi di tie C s on fu D si em on en or Al tia d Fa is co o ilu ho rie re lo nt to at rd io fo ru n llo g w in to ad x vi ic ce at io or n in s Af tru C fe c er tio ct eb ed ns La ro by ng va sc m ua ed ul ge ar ic or at Ac io sp ci n ee de ch nt Ve or ba P ry Tr rri h a n ys er il l, ic s si fra al e nt il, im de Is p a ch bi ae irm lit at e m ed ic nt s Ac or ci ge de ne nt ra ld et er io ra t io U n ns te ad y on fe et
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 In 2007-08 the five patient contributing factors most commonly associated with Behaviour incidents (excluding the other contributing factor category) were: Mental health related (55.9% of all Behaviour incidents have this contributing factor) Patient co-morbidities (16.4%) Dementia (13.2%) Confusion or disorientation (13.2%) Alcohol or drug intoxication (11.0%).
Figures 30 shows the number of Behaviour incidents associated with alcohol or drug intoxication each year since AIMS notification commenced. In 2001-02, alcohol was identified as a contributing factor in 7.7% of Behaviour incidents compared to 11.4% in 2006-07 and 11.0% in 2007-08.
Figure 30: Number of Behaviour Incidents with Alcohol or Drug Intoxication as a Contributing Factor 2001-08
Number of Behaviour Incidents with Alcohol/Drug Intoxication as a Contributing Factor 2001-2008 450 424 400 344 350 300 281 250 218 200 150 100 50 0 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 187 344
90
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Patient Demographics In 2006-07 the number and rate of behaviour incidents peaked in the 20-34 year age group (Figure 31a). Maximum rates of Behaviour incidents reached 4.9 and 4.3 incidents per 1,000 bed days for those aged 20-24 years and 30-34 years respectively.
Similar results were observed in 2007-08 with the number and rate of Behaviour incidents peaking in the 20-34 year age group (Figure 31b). Maximum rates of Behaviour incidents reached 6.0 and 6.5 incidents per 1,000 bed days for those aged 20-24 years and 30-34 years respectively. Figure 31a: Number and Rate of Behaviour Incidents by Age Group 2006-07
350 6
300
5 Rate of incidents per 1,000 bed days
Number of behaviour incidents
250 4 200 3 150 2 100
50
0
10 -1 4 15 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 65 -6 9 60 -6 4 70 -7 4 75 -7 9 80 -8 4 04 85 + 59
Age Group Number of incidents Rate of Incidents per 1,000 Bed days
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 31b: Number and Rate of Behaviour Incidents by Age Group 2007-08
600 Number of Behaviour Incidents 500 400 300 3 200 100 0 2 1 0 7 6 5 4 Rate of Behaviour Incidents per 1,000 Bed Days
Males were involved in 60.3% all Behaviour incidents in WA during 2006-07 (Figure 32a) and 55.6% of incidents in 2007-08 (Figure 32b).
Figure 32a: Proportion of Behaviour Incidents by Gender 2006-07
y 5- ear s 9 10 ye -1 ar 4 s 15 ye -1 ar s 9 20 ye -2 ar s 4 25 ye -2 ar s 9 30 ye -3 ar s 4 35 ye -3 ar 9 s 40 ye -4 ar s 4 45 ye -4 ar s 9 50 ye -5 ar s 4 55 ye -5 ar 9 s 60 ye -6 ar s 4 65 ye -6 ar s 9 70 ye -7 ar s 4 75 ye -7 ar s 9 80 ye -8 ar 4 s y 85 e a + rs ye ar s
Age Group
04
Rate of Behaviour Incidents per 1,000 Bed Days
39.7%
55.6%
Male
Female
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Figure 32b: Proportion of Behaviour Incidents by Gender 2007-08

2.3%
42.1%
55.6%
Male
Female
Not Stated
3.4.3 Discussion Literature on this incident category68, 70 cites aggressive behaviour as the most common type of Behaviour incident in the healthcare setting. This is also reflected in WA AIMS data with physical and verbal aggression contributing to the majority of Behaviour incidents (72.7% 2006-07 and 80.3% in 2007-08). Not only are aggressive Behaviour incidents the most common subcategory, they also tend to result in one of the highest proportions of significant outcomes.
Both mental health and emergency care facilities in 2006-07 and 2007-08 notified a significant proportion of the Behaviour incidents to AIMS (67.3% 2006-07 and 73.6% 2007-08 of all incidents in this category). However, the top three Behaviour incident types for each area of health were slightly different. While both mental health and emergency care facilities reported physical and verbal aggression incidents in their top three, mental health facilities recorded intended self harm, and emergency care facilities recorded absconding within the top three Behaviour incident types. These different Behaviour incident types reflect the different roles of these health areas in WA Health.
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Mental health issues, dementia, alcohol and drug intoxication, as well as patient comorbidities played a significant role in the Behaviour incidents reported to AIMS in WA. These patient contributing factors are consistent with those reported in the literature.68-71
Behaviour incidents in Australian hospitals receive frequent media attention, especially in conjunction with reports of increased binge drinking and a rise in psychosis and emergency presentations associated with crystalline methamphetamine (ICE) abuse.57-59 Overall in WA, the number of these Behaviour incidents reported to AIMS has increased over time.
In mental health facilities processes and guidelines are in place to deal with violent aggressive patients. These include the chemical or physical restraint or seclusion of the patient. Guidelines for staff to deal with violent behaviour may be utilised by emergency care facilities but this varies across the State. Procedures for dealing with violent behaviour have been developed for the safety of staff and patients, as well as for the safety of the violent or aggressive patient.
Behaviour incidents occur across the age spectrum. However, the greatest number of incidents occurred in the 15-39 (2006-07) and 20-34 (2007-08) year age brackets. Smaller peaks of Behaviour incidents in relation to both number and rate, occurred in patients aged over 69 years (2006-07) and 74 years (2007-08) and this is likely to be attributed to dementia and other impairments associated with advancing age. Behaviour incident rates for this age group displayed a similar pattern. Violence prevention strategies across WA health services remain an important initiative to decrease violent behaviour in the future.
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3.4.4 Key Messages Between 1 July 2006 and 30 June 2007 Behaviour incidents represented 12.0% of all incident notifications to AIMS making it the fourth most commonly reported incident type. Between 1 July 2007 and 30 June 2008 Behaviour incidents represented 14.1% of all incident notifications to AIMS making it the third most commonly reported incident type. Since 2001-02 the rate of reported Behaviour incidents has increased from 0.8 to 2.5 incidents per 1,000 bed days in 2007/08. The most common types of Behaviour incidents are physical abuse, aggression or assault, verbal abuse or aggression, and absconding. The majority of contributing factors related to patient factors and include mental health issues, dementia and alcohol or drug intoxication. The rate of Behaviour incidents was highest in the 20-34 age group for both 200607 and 2007-08.
3.5 Other Incidents

3.5.1 Introduction A significant number of clinical incidents do not fit within the defined nine Principal Incident Types (PITs) and are therefore categorised as Other incidents in the AIMS database.
In 2007-08 there were 3,499 incidents notified within this category between 1 July 2007 and 30 June 2008, representing 12.8% of all incidents. This represents a decrease in 2007-08 of 246 or 7.0% of incidents compared to 2006-07. Over time, the number of reported incidents that do not fit within the nine PITs has ranged between the third and fourth most notified category of incidents. In 2006-07, Other incidents ranked as the third most notified incident type and the fourth in 2007-08.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 3.5.2 Results Other Incidents 2006-07 and 2007-08 This incident category is subdivided into eight broad subcategories as indicated in Figures 33a and 33b. The proportion of incidents included in each of these subcategories is also shown. The category no, wrong, delayed procedure, treatment or assessment made up more than half of the incidents categorised in the Other PIT. Figure 33a: Number and Percent of Other Incidents by Other Incident Type Category (2006-07) 27
1,800 1,600 Number of other incident types 1,400 1,200 1,000 800 600 400 200 0
# em er ge nc y pa H rt os or pi ta si de la cq ui N re o/ d w in ro fe ng ct /d io el n ay ed di ag no si s pr oc ed u ad m is si on pl an ni ng O th er re *
51.0%
17.2%
16.7% 9.5% 4.2% 3.4% 2.9% 2.4%
M ed ic al
di sc ha rg e W ro ng
or de la ye d
o/ de la ye d
Po or
* No, wrong or delayed procedure, treatment or assessment # No or delayed admission, inappropriate bed/ward
27
An incident can be associated with more than one incident type.
ro ng
pa tie nt
or bo dy
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 33b: Number and Percent of Other Incidents by Other Incident Type 2007-08
2,500 Number of Other Incident Types 50.7%
2,000
1,500
1,000
19.6% 12.6%
500 5.0% 0
e* di ag no s is nn in g pa rt Ho or sp s id it a e la cq ui re d in fe ct io n O th er io n# pr oc ed ur er ge nc y iss
4.3%
3.2%
2.5%
2.2%
ad m
or de la ye d
ay ed
wr on g
* No, wrong or delayed procedure, treatment or assessment # No or delayed admission, inappropriate bed/ward
For clarity, trends, Outcome Levels and demographics in this section are reported separately for each of the subcategories in the Other PIT.
No, Wrong, Delayed Procedure, Treatment or Assessment In 2007-08 there were 1,945 incidents in the category of no, wrong, delayed procedure, treatment or assessment (50.7% of all Other incidents) notified to AIMS, compared to 1,658 such incidents in 2006-07 (an increase of 14.8%).
Of these incidents, 27.1% (2006-07) and 35.6% (2007-08) were associated with no harm to the patient, 61.1% (2006-07) and 51.2% (2007-08) with minor to moderate harm to the patient requiring review by a doctor and extra monitoring or minor diagnostic investigations or treatment (e.g. x-ray, dressings, analgesia or extra treatment not otherwise needed) and 11.6% (2006-07) and 12.8% (2007-08) with significant to severe harm (e.g. an increased length of stay in hospital, permanent disability or death). In 2006-07 seven of these incidents were associated with patient death compared with 18 in 2007-08.
W ro ng
No ,
No
or
pa t ie nt or bo dy
de la ye d
ed ic
No
ro ng
Po or di s
or de l
or
ch ar ge
al e
pl a
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 In 2006-07 the number of incidents in this Other subcategory increased with age, peaking in the 70 to 74 year age group, with a smaller peak in the 0 to 4 year age group (Figure 34a). The rate of incidents per 10,000 bed days showed that the main age group peaks were for those 50 to 54 years and 70 to 79 years. The rate of reported no, wrong, delayed procedure, treatment assessment incidents is lowest in the oldest age groups (75+ years) with a rate ranging from 7.6 to 9.1 incidents per 10,000 bed days.
In 2007-08 the number of incidents in this Other subcategory increased with age peaking in the 30-34 year age group, with a slightly smaller peak in the 0-4 year age group (Figure 34b). The rate of incidents per 10,000 bed days shows a decreasing trend as patient age increases with the highest rate in the 10-14 year age group (17.6 incidents per 10,000 bed days) and the lowest rate in the 85+ year age group (5.1 incidents per 10,000 bed days).
Examples of the types of incidents included in this subcategory include: Delayed transfer Delay or incorrect investigations (e.g. x-rays, blood tests) Cancelled procedures because test results not performed or available Care not attended adequately or as ordered.
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Number of Incidents
0 -4
Number of Incidents
100 120 20 40 60 80 0
5
140
160
180
100
120
140
20
40
60
80
Figure 34a: Number and Rate of No, Wrong, Delayed Procedure, Treatment or Assessment Incidents by Age Group 2006-07
Figure 34b: Number and Rate of No, Wrong, Delayed Procedure, Treatment or Assessment Incidents by Age Group 2007-08
Number of Incidents
Number of Incidents
Age Group
Age Group
04 y 5- ea 10 9 y rs -1 ea 15 4 y rs -1 e a 20 9 y rs -2 e a 25 4 y rs -2 e a 30 9 y rs -3 e a 35 4 y rs -3 e a 40 9 y rs -4 e a 45 4 y rs -4 e a 50 9 y rs -5 e a 55 4 y rs -5 e a 60 9 y rs -6 e a 65 4 y rs -6 e a 70 9 y rs -7 e a 75 4 y rs -7 e a 80 9 y rs -8 e a 4 rs 85 ye + ars ye ar s
Rate of Incidents per 10,000 Bed Days
10
12
14
16
18
20
ye - 9 ars 10 ye - 1 ar s 15 4 y e - 1 ar s 9 20 ye - 2 ar s 25 4 y e - 2 ar s 9 30 ye a -3 rs 35 4 y e - 3 ar s 9 40 ye - 4 ar s 45 4 y - 4 ear s 9 50 ye - 5 ar s 55 4 y e - 5 ar s 9 ye 60 a -6 rs 65 4 y e a -6 rs 9 70 ye - 7 ar s 75 4 y to ea rs 7 80 9 y e to a 84 rs ye 85 ars + ye ar s
10
12
14
16
18
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Other In 2007-08 there were 667 incidents that did not fit into one of the eight Other subcategories (19.0% of all Other incidents), compared to 558 incidents in 2006-07 (an increase of 16.3%).
Examples of types of incidents included in this subcategory include: Specimens lost, or incorrectly transported or stored Communication issues between departments or handover between staff Operation sites not marked Complications arising from surgery.
Of these incidents, 28.7% (2006-07) and 33.7% (2007-08) were associated with no harm to the patient, 46.7% (2006-07) and 42.0% (2007-08) with a minor to moderate level of harm to the patient, and 24.4% (2006-07) and 23.1% (2007-08) with significant to severe harm. A total of nineteen incidents were associated with patient death in 2006-07 compared with ten in 2007-08.
The number and rate of incidents in the Other subcategory of the Other PIT (Figures 35a and 35b) peaked across the age groups spanning 20 to 39 years (7.1 to 8.1 incidents per 10,000 bed days 2006-07 and 9.2 to 10.5 incidents per 10,000 bed days 2007-08) as well as the 0-4 year age group (5.6 incidents per 10,000 bed days 200607 and 6.7 incidents per 10,000 bed days 2007-08).
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Number of Incidents
0 -4
10 20 30 40 50 0 Number of Incidents
04
10
5 -9
20
30
40
50
60
70
80
90
60
70
Figure 35a: Number and Rate of Other Incidents by Age Group 2006-07
Figure 35b: Number and Rate of Other Incidents by Age Group 2007-08
Number of Incidents
Number of Incidents Age Group Rate of Incidents per 10,000 Bed Days
Age Group 0 Rate of Other Incidents per 10,000 Bed Days 2 4 6 8 10 12
ye 5- ars 9 10 yea -1 r 4 s 15 y ea -1 rs 9 20 y ea -2 rs 4 25 y ea -2 rs 9 30 y ea -3 rs 4 35 y ea -3 rs 9 40 y ea -4 rs 4 45 y ea -4 rs 9 50 y ea -5 rs 4 55 y ea -5 rs 9 60 y ea -6 rs 4 65 y ea -6 rs 9 70 y ea -7 rs 4 75 y ea -7 rs 9 80 y ea -8 rs 4 ye a 85 rs + ye ar s
ye ar s ye 10 a -1 rs 4 ye 15 - 1 ar s 9 ye 20 - 2 ar s 4 ye 25 - 2 ar s 9 ye 30 - 3 ar s 4 ye 35 - 3 ar s 9 ye 40 - 4 ar s 4 ye 45 - 4 ar s 9 ye 50 - 5 ar s 4 ye 55 - 5 ar s 9 ye 60 - 6 ar s 4 ye 65 - 6 ar s 9 ye 70 - 7 ar s 4 ye 75 - 7 ar s 9 ye 80 - 8 ar s 4 ye 85 ars + ye ar s
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Number of incidents per 10,000 Bed Days
Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 No or Delayed Admission, Inappropriate Bed or Ward In 2007-08 there were 440 incidents reported in the no or delayed admission, inappropriate bed or ward category (12.6% of all Other incidents), compared to 543 incidents in 2006-07 (a decrease of 18.9%).
Examples of the types of incidents included in this subcategory include: Lack of ward beds leading to a prolonged stay and the preparation of patients for theatre in the emergency department Acutely psychotic patients allocated a bed in a medical ward.
Of these incidents, 30.4% (2006-07) and 52.3% (2007-08) were associated with no harm to the patient, 65.8% (2006-07) and 38.0% (2007-08) with a minor or moderate level of harm to the patient, and 3.8% (2006-07) and 8.6% (2007-08) with significant to severe harm. There were no patient deaths associated with these incidents in 2006-07 and two deaths in 2007-08. In 2006-07 the number of reported incidents in the no, delayed admission, inappropriate bed or ward category (Figure 36a) peaked in the 65 to 69 and 75 to 79 age groups with very few of this type of Other incident type reported in the younger age groups (0 to 14 years). The rate of these incidents peaked in the 20 to 24 year age group (5.4 incidents per 10,000 bed days) trending down to a rate of 2.0 incidents per 10,000 bed days for the 85+ year age group.
In 2007-08 the number of reported incidents in the no or delayed admission, inappropriate bed or ward category (Figure 36b) peaked in the 30 to 34 years age group and the 50 to 54 year age group. The rate of these incidents peaked in the same age groups with 5.0 incidents per 10,000 bed days in the 30 to 34 year age group and 5.6 incidents per 10,000 bed days in the 50 to 54 year age group.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 36a: Number and Rate of No, Delayed Admission, Inappropriate Bed or Ward Incidents by Age Group (2006-07)
60 6 Number of Incidents per 10,000 Bed Days
50 Number of Incidents
40
30
20
10
0
ye 5- ars 9 ye 10 ar s -1 4 ye 15 ar -1 s 9 y ea 20 rs -2 4 ye 25 ar -2 s 9 30 yea rs -3 4 ye 35 ar -3 s 9 ye 40 ar -4 s 4 45 yea rs -4 9 ye 50 ar -5 s 4 ye 55 ar -5 s 9 60 yea rs -6 4 ye 65 ar -6 s 9 70 yea rs -7 4 ye 75 ar -7 s 9 ye 80 ar -8 s 4 ye 85 ars + ye ar s
04
Age Group Number of Incidents Rate of Incidents per 10,000 Bed Days
Figure 36b: Number and Rate of No or Delayed Admission, Inappropriate Bed or Ward Incidents by Age Group (2007-08)
50 45 40 Number of Incidents 35 30 25 20 15 10 5 0
ye ar s ye a 10 rs -1 4 ye ar 15 s -1 9 ye 20 ar s -2 4 ye ar 25 s -2 9 ye ar 30 s -3 4 ye 35 ar s -3 9 ye ar 40 s -4 4 ye a 45 rs -4 9 ye ar 50 s -5 4 ye 55 ar s -5 9 ye ar 60 s -6 4 ye ar 65 s -6 9 ye 70 ar s -7 4 ye ar 75 s -7 9 ye ar 80 s -8 4 ye ar s 85 + ye ar s
6 5 4 3 2 1 0 Rate of Incidents per 10,000 Bed Days
04
59
Age Group Number of Incidents Rate of Incidents per 10,000 Bed Days
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Medical Emergency The medical emergency subcategory included incidents involving either a medical emergency or the response of a Medical Emergency Team (MET).
In 2007-08 there were 190 incidents (5.0% of all Other incidents) in this subcategory compared to 309 in 2006-07, a decrease of 38.5%.
Examples of the types of incidents included in this subcategory include: Patients suffering a cardiac or respiratory arrest Patients or visitors fainting and sustaining injuries Patients experiencing a grand-mal seizure.
Of these incidents, 1.0% (2006-07) and 2.8% (2007-08) were associated with no harm to the patient, 76.3% (2006-07) and 55.9% (2007-08) with minor to moderate harm to the patient, and 22.7% (2006-07) and 41.3% (2007-08) with significant to severe harm. In 2006-07 21 of these incidents were associated with patient death compared with 19 in 2007-08.
Figure 37a shows that in 2006-07 both the number and the rate of medical emergency incidents peaked in the 0 to 4 year age group (2.0 incidents per 10,000 bed days) and in the 50 to 54 age group (2.1 incidents per 10,000 bed days). Note that over 50% of medical emergency incidents do not list patient age.
Figure 37b shows that in 2007-08 both the number and rate of medical emergency incidents peaked in the 0 to 4 year age group (1.9 incidents per 10,000 bed days) with a second smaller peak in the 40 to 44 year age group (1.6 incidents per 10,000 bed days).
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Number of Incidents
04
Number of Incidents 10 12 14 16 18 0 2 4 6 8
10
12
14
16
18
Figure 37a: Number and Rate of Medical Emergency Incidents by Age Group 2006-07
Figure 37b: Number and Rate of Medical Emergency Incidents by Age Group 2007-08
Number of Incidents
Number of Incidents
Age Groups
Age Group
04 5- yea 10 9 y r s -1 ea 15 4 y r s -1 e a 20 9 y rs -2 e a 25 4 y rs -2 e 30 9 y ars -3 e a 35 4 y rs -3 e a 40 9 y rs -4 e a 45 4 y rs -4 e a 50 9 y rs -5 e a 55 4 y rs -5 e a 60 9 y rs -6 e a 65 4 y rs -6 e a 70 9 y rs -7 e 75 4 y ars -7 e a 80 9 y rs -8 e a 4 r 85 ye s + ars ye ar s

ye 5- ars 9 10 y e -1 ars 4 15 y e -1 ars 9 20 y e -2 ars 4 25 y e -2 ar s 9 30 y e a -3 4 rs 35 y e -3 ars 9 40 y e -4 ar s 4 45 y e -4 ars 9 50 y e -5 ars 4 55 y e -5 ar s 9 60 y e a -6 4 rs 65 y e -6 ars 9 70 y e -7 ar s 4 75 y e -7 ars 9 80 y e -8 ars 4 y 85 ear s + ye ar s
0.0 Rate of Incidents per 10,000 Bed Days
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
2.0
Number of Incidents per 10,000 Bed Days
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 No, Wrong or Delayed Diagnosis In 2007-08 there were 163 incidents reported in the no, wrong or delayed diagnosis category representing 4.3% of all Other incidents. This compares to 79 incidents in 2006-07, an increase of 48.5%.
Examples of types of incidents included in this subcategory include: Breech presentations diagnosed late in labour Ovarian cysts misdiagnosed as appendicitis Missed fractures on X-rays.
Of these incidents, 8.2% (2006-07) and 47.9% (2007-08) were associated with no harm to the patient, 63.9% (2006-07) and 40.1% (2007-08) with minor to moderate harm to the patient, and 27.9% (2006-07) and 12.0% (2007-08) with significant to severe harm. Three of these incidents were associated with patient death in 2006-07 compared with two patient deaths in 2007-08. When analysed by age group, in 2006-07, 35 to 39 year olds recorded the greatest number of such incidents (Figure 38a). The rate of incidents followed a similar trend, also peaking in the 35 to 39 year age group at 1.6 incidents per 10,000 bed days. Overall, the trend for these incidents is higher in the lower age groups than the older age groups.
In 2007-08, the 25 to 29 year age group recorded the greatest number of no, wrong or delayed diagnosis incidents (Figure 38b). The rate of this incident type peaked in the 10 to 14 year age group with 2.8 incidents per 10,000 bed days. Overall, there is a decreasing trend in the rate of this incident type from the youngest to the oldest age groups.
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Number of Incidents
Number of Incidents
04
04
10 12 14
10
12
0
0 2 4 6 8
Number of Incidents
Figure 38a: Number and Rate of No, Wrong or Delayed Diagnosis Incidents by Age Group 2006-07
Figure 38b: Number and Rate of No, Wrong or Delayed Diagnosis Incidents by Age Group 2007-08
Number of Incidents
Age Group
Age Group
Rate of Incidents per 10,000 Bed Days 0.5 1.0 1.5 2.0 2.5 3.0
y 5- ear 9 10 ye s -1 ar 15 4 ye s -1 ar 9 20 ye s -2 ar 4 25 ye s -2 ar 9 s 30 ye -3 ar s 4 35 ye -3 ar 9 40 ye s -4 ar 45 4 ye s -4 ar 9 50 ye s -5 ar 4 55 ye s -5 ar 9 s 60 ye -6 ar s 4 65 ye -6 ar 9 70 ye s -7 ar 75 4 ye s -7 ar 9 80 ye s -8 ar 4 s 85 ye a r + ye s ar s
y 5- ears 9 10 y e -1 ars 4 15 y e -1 ar s 9 20 y e -2 ar s 4 25 y e -2 ar s 9 30 y e -3 ars 4 35 y e -3 ar s 9 40 y e -4 ar s 4 45 y e -4 ar s 9 50 y e -5 ar s 4 55 y e -5 ar s 9 60 y e -6 ars 4 65 y e -6 ar s 9 70 y e -7 ar s 4 75 y e -7 ar s 9 80 y e -8 ar s 4 y 85 ear s + ye ar s
0.0
0.0
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0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Poor Discharge Planning In 2007-08 there were 121 incidents reported in this category, representing 3.2% of all Other incidents. This compares to 156 incidents in 2006-07, a decrease of 22.5%.
Examples of the types of incidents included in this subcategory include: Patients leaving hospital without health-related instructions or information Patients leaving hospital with inadequate support Delayed discharge Discharge medications not given to patient prior to discharge.
Of these incidents, 42.1% (2006-07) and 46.7% (2007-08) were associated with no harm to the patient, 45.8% (2006-07) and 42.1% (2007-08) with a minor or moderate level of harm to the patient, and 12.1% (2006-07) and 11.2% (2007-08) with significant to severe harm. One patient death was associated with this subcategory in 2006-07 compared with no deaths in 2007-08. Although the number of these incidents per age group is relatively small (Figure 39a), in 2006-07 the overall rate ranges from 0.3 to 1.2 incidents per 10,000 bed days with the rate peaking in the 45 to 49 year age.
In 2007-08 the number of incidents per age group is small (Figure 39b), peaking in the 80 to 84 year age group. The overall rate ranges from 0.1 to 1.8 incidents per 10,000 bed days, peaking in the 15 to 19 year age group.
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Number of Incidents
Number of Incidents
04
04
10 15 20 25
10 12 14
16
0
0 2 4 6 8
Number of incidents
Figure 39a: Number and Rate of Poor Discharge Planning Incidents by Age Group 2006-07
Figure 39b: Number and Rate of Poor Discharge Planning Incidents by Age Group 2007-08
Number of Incidents
Age Group
Age Group
Number of incidents per 10,000 bed days
Rate of Incidents per 10,000 Bed Days 0.4 0.6 0.8 1.0 1.2 1.4 1.6 1.8 2.0
0.0
0.2
0.0
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0.2
0.4
0.6
0.8
1.0
1.2
1.4
Wrong Patient, Body Part or Side In 2007-08 there were 97 incidents where a procedure was reported to have been performed on the wrong patient, wrong body part or wrong side of the body, representing 2.5% of all Other incidents. This compares to 119 incidents in 2006-07, a decrease of 18.5%. Note that this category of clinical incident is also a reportable national sentinel event category3, 73 that requires mandatory notification to the Office of Safety and Quality in Healthcare and subsequent in-depth investigation.
Examples of the types of incidents included in this subcategory include: X-rays performed on the wrong patient Nerve blocks performed on the wrong limb Extractions of the wrong teeth.
Of these incidents, 63.9% (2006-07) and 69.5% (2007-08) were associated with no harm to the patient, 30.6% (2006-07) and 28.4% (2007-08) with a minor to moderate level of harm to the patient, and 5.6% (2006-07) and 2.1% (2007-08) with significant to severe harm. No patient deaths were associated with this subcategory in 2006-07 and 2007-08. While the number of wrong patient, body part, side incidents is small, in 2006-07 they peak in the younger age groups (0 to 24 years) trending downwards with increasing age (Figure 40a). The rate of these incidents follows a similar trend with the highest rate occurring in the 5 to 9 year age group (4.7 incidents per 10,000 bed days) and the lowest rate occurring in the 85+ year age group (0.2 incidents per 10,000 bed days).
In 2007-08 incidents peak in the 60 to 64 year age group with a smaller peak in the 25 to 29 year age group (Figure 40b). The rate of these incidents peaks in the younger age groups (5 to 14 years) (2.3 to 3.2 incidents per 10,000 bed days) and then remains relatively stable across the older age groups.
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Number of Incidents
Number of Incidents
04
04
10 12
10
12
0
0 2 4 6 8
Number of Incidents
Figure 40a: Number and Rate of Wrong Patient, Body Part, Side Incidents by Age Group 2006-07
Figure 40b: Number and Rate of Wrong Patient, Body Part, Side Incidents by Age Group 2007-08
Number of Incidents
Age Group
Age Group
Rate of Incidents per 10,000 Bed Days 0.5 1.0 1.5 2.0 2.5 3.0 3.5
0.0
0.0
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0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Healthcare Associated Infection In 2007-08 there were 86 healthcare associated infection incidents notified to AIMS, representing 2.2% of all Other incidents. This compares to 97 incidents in 2006-07, a decrease of 11.3%.
Examples of the types of incidents included in this subcategory include: Urinary tract infections related to catheterisation Infected intravenous sites Central venous catheter blood stream-related infections Infected sutures Post-operative wound infections.
Of these incidents, 1.2% (2007-08) were associated with no harm to the patient while 64.5% (2006-07) and 69.4% (2007-08) were associated with minor to moderate harm to the patient, and 35.5% (2006-07) and 29.4% (2007-08) resulted in significant to severe harm. No patient deaths were associated with this subcategory in 2006-07 and 2007-08. In 2006-07 the number of healthcare associated infections incidents shows an increasing upward trend with increasing age, peaking in the 75 to 79 year age group (Figure 41a), the rate of such incidents demonstrates no obvious trends ranging between 0.0 to 1.0 incidents per 10,000 bed days.
In 2007-08 the number and rate of healthcare associated infections peak in the 35 to 39 year age group and the 75 to 79 year age group (Figure 41b). The largest peak for rate of such incidents occurs in the 35 to 39 year age group with 1.3 incidents per 10,000 bed days.
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Number of Incidents
Number of Incidents
04
04
10 12
10
12
14
0
0 2 4 6 8
Number of Incidents
Figure 41a: Number and Rate of Healthcare Associated Infection Incidents by Age Group 2006-07
Figure 41b: Number and Rate of Healthcare Associated Infection Incidents by Age Group 2007-08
Number of Incidents
Age Group
Age Group
Rate of Incidents per 10,000 Bed Days 0.0 Rate of Incidents per 10,000 Bed Days 0.2 0.4 0.6 0.8 1.0 1.2 1.4
ye 5- ars 9 10 y e -1 ars 4 15 y ea -1 rs 9 20 y ea -2 rs 4 25 y e -2 ars 9 30 y ea -3 rs 4 35 y e -3 ars 9 40 y ea -4 rs 4 45 y ea -4 rs 9 50 y e -5 ars 4 55 y ea -5 rs 9 60 y e a -6 4 rs 65 y ea -6 rs 9 70 y ea -7 rs 4 75 y e a -7 9 rs 80 y ea -8 rs 4 ye ar s
0.0
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0.2
0.4
0.6
0.8
1.0
1.2
Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Contributing Factors Sixty-nine percent (2006-07) and 74.8% (2007-08) of contributing factors for all Other incidents were attributed to staff-related factors and 21% (2006-07) and 16.3% (200708) were attributed to patient-related factors.
The three most common staff contributing factors for incidents classified as Other (Table 16) were communication problem (25.4% 2006-07 and 28.0% 2007-08 of all Other incidents), failure to follow policy or procedure (21.1% 2006-07 and 20.9% 2007-08) and inadequate knowledge or inexperience (13.2% 2006-07 and 14.7% 2007-08). Table 16: Number and Percent of Other Incidents by Type of Staff Contributing Factor 2006-07 and 2007-08 28
2006-07 Contributing Factor Number Proportion of Other of all Other Incidents Incidents 824 686 25.4% 21.1% Contributing Factor 2007-08 Number of Other Incidents 1,074 802 Proportion of all Other Incidents 28.0% 20.9%
Communication problem Failure to follow policy or procedure Inadequate knowledge or inexperience Other Staff did not attend when required Insufficient or inadequate staff Multiple staff or poor continuity Failure to follow advice or instructions Poor teamwork or supervision Misread or didnt read document
430 403 335 279 248
13.2% 12.4% 10.3% 8.6% 7.6%
158
4.9%
148 134
4.6% 4.1%
Communication problem Failure to follow policy or procedure Inadequate knowledge or inexperience Other Insufficient or inadequate staff Poor teamwork or supervision Staff did not attend when required Misread or did not read documentation Failure to follow advice or instructions Multiple staff or poor continuity
564 453 236 228 154
14.7% 11.8% 6.2% 5.9% 4.0%
141
3.7%
134 113
3.5% 2.9%
28
A single incident can have more than one contributing factor assigned to it.
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Table 16: Number and Percent of Other Incidents by Type of Staff Contributing Factor 2006-07 and 2007-08 CONT29 2006-07 2007-08 Contributing Number of Proportion of Contributing Number of Proportion of Factor Other all Other Factor Other all Other Incidents Incidents Incidents Incidents Fatigue or Fatigue or stress or stress or 45 1.4% 71 1.9% unwell unwell Pressure to proceed Distraction or inattention Medication not reviewed No PRN medications ordered PRN medications not used 44 1.4% Distraction or inattention Pressure to proceed No PRN medications ordered Medication not reviewed 42 1.1%
34
1.0%
37
1.0%
0.2%
0.2%
0.2%
0.0%
0.0%
3.5.3 Discussion The Other category in the AIMS database includes those incidents that do not fit within one of the nine defined Principal Incident Types (PITs). Analysis of Outcome level data demonstrates that incidents in this category tend to have a greater proportion associated with significant and severe outcomes such as increased length of stay, permanent disability or death than any of the other PITs. This is evidenced by the fact that 51 deaths were recorded in this category in both 2006-07 and 2007-08, more than any other category in AIMS. Incidents resulting in death and other severe outcomes are investigated by the hospital or health service using a process called Root Cause Analysis (RCA) or similar methodology, whereby causes of the incidents are discovered and strategies implemented to prevent their recurrence.
Over a quarter of notified AIMS incidents classified as Other report communication problems as a contributing factor to the incident. Communication issues are also a significant contributing factor reported in sentinel events. In 2006-07 over 80% of sentinel events notified to the OSQH reported communication as a contributing factor
29
A single incident can have more than one contributing factor assigned to it.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 with approximately 60% in 2007-08. Consequently, staff should be aware of the importance of communication, especially in circumstances such as hand-over and surgical procedures.
Comparison of the significant to severe Other AIMS incidents with incidents captured in the Sentinel Event database indicates that not all incidents are captured within AIMS. However, there are several other systems in place in WA that capture information on significant clinical events, including contributing factors and recommendations. In this way lessons can be learnt from these incidents and shared across all of WA Health. For example, with the aim of capturing knowledge of preventable deaths, the Office of Safety and Quality in Healthcare implemented the WA Review of Mortality (WARM) Policy2 to ensure that all in-patient deaths are reviewed. In addition, the Sentinel Event Policy,3 also implemented by the OSQH, seeks to study preventable catastrophic incidents that lead to the permanent disability or death of a patient, while WA surgeons have implemented the WA Audit of Surgical Mortality (WAASM)4 which reviews those patient deaths that occur while under the care of a surgeon. These systems, including AIMS, act as a net with which to capture clinical incidents and significant events, to ensure such incidents do not occur again.
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3.5.4 Key Messages The number of reported incidents that are categorised as Other has increased over time with this category representing the third (2006-07) and fourth (2007-08) most notified category of clinical incidents. In addition, analysis of Outcome Level data indicates that this category is second only to Behaviour incidents for having the greatest number of incidents with significant to severe outcomes (increased length of stay, permanent disability or death). Almost three quarters of contributing factors were staff-related factors with communication problems, failure to follow policy or procedure, and inadequate knowledge or inexperience reported as the three most common contributing factors. Clinical incidents resulting in permanent harm or death are investigated using the Root Cause Analysis investigation process or similar methodology. In this way causes can be discovered and recommendations implemented to prevent such incidents from occurring again. Other systems are also in place to capture information on catastrophic clinical incidents. For example, the WA Review of Mortality (WARM) Policy,2 the Sentinel Event Policy,3 and the WA Audit of Surgical Mortality (WAASM)4 have also been implemented to capture information from these incidents and to prevent them from occurring again.
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3.6 Injury Incidents

3.6.1 Introduction The term injury in the AIMS process includes any form of clinical incident that physically harms a patient. Injuries associated with healthcare may include wounds, burns and pressure ulcers. Wounds may result from accidents during surgery or attributed to the hospital environment. Age and frailty of the patient are significant contributing factors in the acquisition of such injuries.74-75
The most frequently notified forms of Injury incidents in WA hospitals are pressure ulcers. Pressure ulcers are a result of prolonged pressure on the skin. Patient risk factors include age, mobility, dry skin and decreased body weight.74 Low staffing levels pose an environmental risk to the development of pressure ulcers.76 Patients who have difficulty moving or are bed-ridden for long periods of time are at risk of developing pressure ulcers.
3.6.2 Results Injury Incidents in 2007-08 Between 1 July 2007 and 30 June 2008 there were 2,492 Injury incidents notified to AIMS, representing 9.1% of all notifications to the system. There were 172 fewer Injury incidents notified in 2007-08 compared to 2006-07 (a decrease of 6.9%).
Trends in Injury Incidents in 2001-08 Since 2004-05 Injury incidents have consistently been the fifth most notified incident type, with an average of 2,227 incidents notified per year. The rate of Injury incidents has fluctuated slightly between 1.6 and 1.7 incidents per 1,000 bed days since 200304 (Table 17).
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Table 17: Number and Rate of Injury Incidents per Year (2001-08) 30
Number of Injury Incidents 936 2,194 2,405 2,514 2,336 2,295 2,492 Number of Bed Days 1,393,388 1,477,925 1,446,603 1,513,179 1,491,433 1,494,006 1,548,462 Rate/1,000 Bed Days 0.7 1.5 1.7 1.7 1.6 1.5 1.6
2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08
Injury incidents represented 10% of the total number of incidents notified in 2006-07 and 9.1% in 2007-08.
Outcome The majority (93.5% 2006-07 and 95.1% 2007-08) of Injury incidents were associated with a minor or moderate level of harm to the patient, requiring review by a doctor and extra treatment or diagnostic investigations (e.g. implementation of pressure area relieving devices, minor dressings, physiotherapy, occupational therapy, blood tests or X-rays) (Figures 42a and 42b). Incidents associated with significant to severe harm (e.g. an increased length of stay in hospital, hospital admission/readmission, transfer to ICU, resuscitation, permanent disability or death) represented 1.8% (2006-07) and 2.6% (2007-08) of all Injury incidents. There were no incidents associated with patient death in this category for 2006-07 and three patient deaths in 2007-08.
Implementation of AIMS was commenced in October 2001, therefore data from 2001-02 is not for a full year.
30
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 42a: Percent of Injury Incidents by Outcome Level Category (2006-07)
1.8%
4.6%
93.5%
No Harm (Outcome Level 1-3) Minor to Moderate Harm (Outcome Level 4-6) Significant Outcome/Death (Outcome Level 7-8)
Figure 42b: Percent of Injury Incidents by Outcome Level Category (2007-08)

2.4%
2.6%
95.1%
No Harm (Outcome Level 1-3) Minor to Moderate Harm (Outcome Level 4-6) Significant Outcome/Death (Outcome Level 7-8)
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Type of Injury Injury incidents can be classified into seven subcategories as displayed in Figures 43a and 43b. Of these subcategories, pressure ulcers have been the most frequently notified type of Injury incident since 2003-04. In 2006-07, 749 or 32.7% of Injury incidents were pressure ulcers with 4.4% of these classed as grade 4 pressure ulcers (the most severe form of pressure ulcer).
In 2007-08, 809 or 32.5% were pressure ulcers with 2.5% of these classed as grade 4 pressure ulcers.
Following pressure ulcers, the three most commonly notified subcategories of Injury incidents were: Unintended injury during procedure or treatment (16.7% 2006-07 and 20.2% 2007-08) (e.g. haematoma formation following IV cannulation, abrasions, tears, bruising from medical equipment such as towel clips, blood pressure cuffs, and unintended visceral trauma / perforations during surgical procedures). Result of impact or collision (18.8% 2006-07 and 17.6% 2007-08) (e.g. bruises, lacerations from knocking or colliding with wheelchairs, beds, bedrails). Other injury (18.1% 2006-07 and 15.4% 2007-08) (e.g. skin tears, abrasions, bruising, swelling from knocking against furniture, bedrails or from use of hoists or assaults from other patients).
These three subcategories have consistently been in the top four reported subcategories since 2001-02.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 43a: Number and Percent of Injury Incidents by Type of Injury Category (2006-07) 31
800 700 32.7%
Number of injury incidents
600 500 400 300 200 100 0

co lli s io n * ig in th er In ju r in ju ry Bu rn lc er ca ls ha or m ed i
12.1% 0.5%
18.8%
18.1%
16.7%
10.6%
3.4% 0.3%
rp s
or N ee dl e st ic k m ed ic al sh ar ps
Pr es su re
te nd ed
fi m pa ct
ni n
U nk
no w
or
or
es u
* Unintended injury during procedure or treatment
Figure 43b: Number and Percent of Injury Incidents by Type of Injury Category (2007-08) 30
900
32.5%
800
Number of Injury Incidents
700 600
20.2%
500 400 300 200 100 0

*
17.6% 15.4%
N
2.4%
or co lli s io n
in
in ju ry
In ju r
Pr es su re
th er
ni nt en de d
es ul to fi m pa ct
* Unintended injury during procedure or treatment

31
An injury incident can be associated with more than one injury type.
nk n
ow
or ig
Bu rn
lc er
ee dl e
st ic k
lt o
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Contributing Factors Patient contributing factors were associated with 88.1% (2006-07) and 45.1% (200708) of Injury incidents. Figures 44a and 44b illustrate the patient contributing factors for all Injury incidents that were notified during 2006-07 and 2007-08.
Figure 44a: Number and Percent of Injury Incidents by Type of Patient Contributing Factor 2006-07 32
1200 Number of injury incidents 1000 800 600 400
46.6%
28.8% 19.5%
9.0%
200 0
6.1%
4.4% 4.0% 3.1% 3.1% 3.0%
1.0% 0.9% 0.9% 0.6% 0.3%
32
More than one contributing factor can be associated with an incident.
Ve ry
oM or bi di tie im il l, s p fra ai rm il , en de ts bi li t at O ed th or er ge D Fa em ne C il u on ra en re ld fu tia si et to on er fo io l lo or ra w di t io so ad n ri e vi ce nt a or ti o in n st ru ct io ns C M VA en ta or lh TI Af ea A fe lth ct ed re la by te m d ed La U i ng c ns a tio ua te n ge ad y or o n sp fe ee W et ch ro ng ba rri or D er is no s tra f oo ct Al io t w co n ea or ho r in lo at rd t e ru nt g io in n to xi ca t io n Ph y si ca l
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Figure 44b: Number and Percent of Injury Incidents by Type of Patient Contributing Factor (2007-08) 33
1,400 Number of Injury Incidents

45.9%
1,200 1,000 800

24.4%
600 400 200 0

nt co -m Ph or ys bi i ca di de l im tie bi s li t pa at irm ed en or ts ge Fa ne il u O r a re th ld er to et fo er l lo io ra w t io ad n vi D ce em C on or en fu in tia si C st on er ru eb o c ti o rd ro va ns is M or sc en ie ul ta nt ar at lh Af Ac io ea fe n ci ct l t de h ed r nt el b at or y ed m Tr ed an i ca si en tio tI n La sc U ng h a n em ua st ea ge .. dy or on sp fe ee W et ch ro ng ba or rri D is er no tra s f c o Al ti o ot co w n ea ho or r lo in at rd te ru nt g io in n to xi ca t io n il l, fra il ,
13.9% 7.5% 7.0% 5.9% 4.3% 3.7% 2.8% 2.5% 1.4% 1.2% 0.8% 0.6% 0.3%
The three most common patient contributing factors were: Patient co-morbidities (46.6% 2006-07 and 45.9% 2007-08 of all Injury incidents) Physical impairments (28.8% 2006-07 and 24.4% 2007-08) Other (19.5% 2006-07 and 13.9% 2007-08).
Patient co-morbidities include age and frailty while physical impairments include difficulty or inability to move, resulting in greater risk of such clinical incidents as pressure ulcers.
Patient Age The number and rate of Injury incidents increased with increasing age (Figures 45a and 45b) with the highest injury rate occurring in those aged 85 years or older (3.7 injuries per 1,000 bed days 2006-07 and 3.4 Injury incidents per 1,000 bed days 2007-08).
33
More than one contributing factor can be associated with an incident.
Ve ry
Pa t ie
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100 200 300 400 500 600
04
Number of Injury Incidents 700 0

ye ar s ye ar s ar s ye ye ar s s s s ye ar ye ar ye ar ye ar
04
100
59 10 -1 4 15 -1 9 20 24 29 34 39 25 30 35 40 -
200
300
400
500
600
700
Figure 45a: Number and Rate (per 1,000 bed days) of Injury Incidents by Age Group 2006-07
Figure 45b: Number and Rate (per 1,000 Bed Days) of Injury Incidents by Age Group 2007-08

Number of incidents Age Group Number of Incidents per 1,000 Bed days
s 44 ye ar 45 s -4 9 ye a 50 rs -5 4 ye ar 55 s -5 9 ye ar 60 s -6 4 ye ar 65 s -6 9 ye ar 70 s -7 4 ye a 75 rs -7 9 ye ar 80 s -8 4 ye ar s 85 + ye ar s
Age Group
Rate of Injury Incidents per 1,000 Bed Days 1.0 1.5 2.0 2.5 3.0 3.5 4.0
0.0
0.0
Rate of Injury Incidents per 1,000 Bed Days
0.5
0.5
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1.0
1.5
2.0
2.5
3.0
3.5
4.0
3.6.3 Discussion Injury incidents notified in WA hospitals reflect the susceptibilities of an aging population, being associated with increased numbers of pressure ulcers and skin tears. This population is associated with co-morbidities and physical impairments, which, coupled with decreased staffing levels, poses a serious risk of injury.74-76 Recommendations derived from Injury incidents reported to AIMS include investigation of severe pressure ulcers using Root Cause Analysis and the review of staff training concerning the formation of pressure ulcers. The 0 to 4 year age group represent a smaller peak in the number and rate of Injury incidents. Injuries here relate to pressure areas from devices such as IV cannula and monitoring probes, burns from IV fluids such as TPN and lipids and bruised heels from heel sticks.
Pressure ulcer prevention is a major focus for many national and international health services including WA Health. In WA, the SQuIRe CPI program mandates evidencebased practice to decrease the incidence of pressure ulcers.32 Working in collaboration with WoundsWest,74 a statewide project aimed at improving patient outcomes, a number of resources have been developed and implemented in AHSs to reduce the incidence of pressure ulcers, including pressure ulcer risk assessment tools and pressure ulcer prevention strategies.
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3.6.4 Key Messages Between 1 July 2006 and 30 June 2007 Injury incidents represented 10% and between 1 July 2007 and 30 June 2008 Injury incidents represented 9.1% of all incident notifications to AIMS making it the fifth most commonly reported incident type. Since 2002-03 the rate of reported Injury incidents has remained relatively stable, fluctuating between 1.5 and 1.7 incidents per 1,000 bed days. Most Injury incidents (93.5% 2006-07 and 95.1% 2007-08) were associated with a minor to moderate level of harm to the patient. Pressure ulcers were the most common type of Injury incident reported in 2006-07 and 2007-08 followed by unintended injury during a procedure or treatment, injuries resulting from an impact or collision, and other injury (skins tears, abrasions, bruising and swelling). The greatest proportion of Injury incidents had patient contributing factors associated with them, including patient co-morbidities and physical impairments. Both the number and rate of Injury incidents reached its peak in the 85 years and over age group. Area Health Services have implemented the SQuIRe Pressure Ulcer CPI Program,77 with the aim of decreasing the number of pressure ulcers in WA hospitals.
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Appendix A: Caveats
The following are noted limitations of incident data collected in the AIMS database:
1. The Quality in Australian Health Care Study estimated that approximately 10% of patients admitted to acute care hospitals experience some form of iatrogenic injury.10 The Australian Patient Safety Foundation, developer of AIMS, estimates that there is under-reporting of incidents. Consequently, we cannot assume that the data presented in this report is representative of all clinical incidents.
2. There is a time-lag between AIMS incident reporting, data entry and classification of clinical incidents.
3. There are occasions when several incidents are notified for the same patient and same incident. For example, a medication omission that occurs several times to a patient before being rectified may result in several separate incidents being notified to AIMS. This can act to artificially inflate the number of incidents. However, there are a number of safety mechanisms in the AIMS process to minimise or avoid duplicate records from entering the system.
4. Percentages may not always add up to 100% due to rounding error.
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Appendix B: AIMS Outcome Levels

Outcome Level Potential Incident Level 1 Dangerous state / potential for harm e.g. understaffed ICU, torn floor covering. Description/Example
Level 2
Intercepted prior to causing harm e.g. wrong medication drawn up but not given, medication allergy identified so medication not given, bed rails not in place.
Actual Incident Level 3 No harm occurred: No change in condition or treatment e.g. harmless medication given to wrong patient.
Level 4
Minor harm occurred not requiring treatment: Reviewed by doctor, extra observations or monitoring, minor harm.
Level 5
Moderate harm occurred: Minor diagnostic investigations (e.g. blood test, x-ray, urinalysis), minor treatment (e.g. dressings, cold pack, analgesia), security or emergency services attendance, allied health review.
Level 6
Moderate harm occurred: Diagnostic investigations (e.g. MRI, CT, surgical intervention), cancellation or postponement of treatment, transfer to another area not requiring increased length of stay, treatment with another medication.
Level 7
Significant harm occurred: Increased length of stay, hospital admission, readmission, transfer to ICU, CPR/resuscitation, secure ward management, seclusion, fractured neck of femur, morbidity which continued at discharge.
Level 8
Severe harm occurred: Permanent disability or death.
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Learning from Clinical Incidents: A Snapshot of Patient Safety in WA 2006-07 and 2007-08 Office of Safety and Quality in Healthcare Western Australian Department of Health 189 Royal Street, EAST PERTH Western Australia 6004 Tel: Fax: Email: Web: (08) 9222 4080 (08) 9222 4014 safetyandquality@health.wa.gov.au http://www.safetyandquality.health.wa.gov.au/home/
Department of Health, 2010
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Delivering Safer Healthcare in Western Australia

The data presented was correct as of July 2009.

Contributing Factor a factor that contributes to the occurrence of an incident.

Harm includes death, disease, injury, suffering and / or disability.

Healthcare Associated Infection potentially preventable infections associated with hospitalisation.

Outcome end result or consequence of an incident to the patient.

Overdose too large a dose of medication.

Pathophysiological factors factors associated with disease.

Key Terms Acronyms

The remainder of this report focuses on these top five PITs.

3.2 Falls Incidents

2001-02 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08

Not Falls Incidents

Figure 3: Number of Falls Incidents by Outcome Level and Year 2002-08

Figure 4b: Percent of Falls Incidents by Outcome Level Category 2007-08

A fall can be associated with more than one injury category.

A fall can be associated with more than one injury category.

15.9% 13.8% 13.1% 10.8% 8.5% 4.3%

3.8% 0.5% 0.4%

A fall can be associated with more than one category.

2.9% 0.5% 0.3%

A fall can be associated with more than one category.

1,800 1,600 Number of Falls Incidents

12 10 Rate of Falls Incidents per 1,000 Bed Days

1,400 1,200 1,000 6 800 600 400 2 200 0

Rate of falls per 1,000 bed days

Age Group Female Male

401 356 217 133 38 33

6.3% 5.6% 3.4% 2.1% 0.6% 0.5%

418 376 236 167 54 51

6.1% 5.5% 3.5% 2.4% 0.8% 0.7%

A fall can be associated with more than one contributing factor.

3.3 Medication Incidents

Figure 9b: Percent of Medication Incidents by Outcome Level Category 2007-08

Number of Medication Incidents

Number of medication incidents

5.7% 4.9% 3.9% 3.8% 2.7% 2.2% 2.1%

5.4% 4.6% 4.1% 3.6% 2.9% 2.3%

A medication incident can have more than one category assigned.

Type of Medication Incident

Table 6: Top 10 Medications Involved in Omission Incidents in WA 2006-07 and 2007-08 9

An incident can be associated with more than one type of medication.

Figure 11b: Percent of Omission Incidents by Outcome Level Category 2007-08

Table 8: Top 10 Medications Involved in Overdose Incidents in WA 2006-07 and 2007-08 11

An incident can be associated with more than one type of medication.

An incident can be associated with more than one type of medication.

* Time was not recorded for 19.2% of data in 2006-07.

Figure 14b: Medication Incidents by Time of Day 2007-08

Number of Medication Incidents

* Time was not recorded for 17.3% of data in 2007-08.

An incident can be associated with more than one type of medication.

An incident can be associated with more than one type of medication.

6 Rate of incidents per 1,000 bed days

Number of medication incidents

600 5 500 4 400 3 300 2 200 1

3.7% 2.7% 0.8%

2.6% 2.5% 0.5%

0.4% 0.4% 0.1% 0.1%

0.4% 0.2% 0.1% 0.1%

An incident can be associated with more than one contributing factor.

Consequently, the majority of Medication incidents reported by staff included as

3.4 Behaviour Incidents

services and aged care settings.60