National & International Initiatives

Page contents: National | International

What is being done nationally in this area?

Every other Australian State/Territory has implemented (or are currently implementing) one common incident reporting software product with one inbuilt methodology for classifying and rating the severity of incidents. This has ensured (or will ensure) consistency across those jurisdictions such that statewide incident data can be aggregated and reviewed.

Some jurisdictions are collecting both clinical and non-clinical incident information in a standardised fashion, whilst others have chosen just to focus on incidents that impact patients, clients and residents.

Some jurisdictions have implemented fully electronic systems, whilst others still utilise a combination of paper based and electronic reporting. At least one has also introduced a call centre whereby incident notifications can be made by any health service staff member over the phone, rather than filling out a paper form.

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What is being done internationally in this area?

Many initiatives have or are currently being undertaken in the area of statewide and/or national incident reporting and learning systems. Below are some relevant examples.

World Health Organisation (WHO)
The WHO International Alliance for Patient Safety commenced a project in 2005 to develop an international patient safety event classification (IPSEC). The project aims to define, harmonize and group patient safety concepts into an internationally agreed classification. A drafting group made of representatives from Australia, USA, Sweden, Switzerland, UK and the Netherlands met for the first time in October 2005. They have since developed a draft IPSEC scheme and are currently testing its components internationally.

For more information, visit the World Health Organisation IPSEC Website .

In 2005, The World Alliance for Patient Safety developed the WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. This is another useful resource that will be utilised as the VHIMS project progresses.

For more information, visit the World Health Organisation Reporting and Learning Website.

Department of Veteran Affairs (VA)
The VA has worked with NASA to develop a Patient Safety Reporting System (PSRS) for their healthcare facilities. This system’s guiding principles are voluntary participation, confidentiality protection, and non-punitive reporting. It is designed to be a complementary external system to the current internal reporting systems used by healthcare services.

For more information visit the Patient Safety Reporting System website.

Minnesota Department of Health (MDH)
The National Quality Forum (US) convened a broad panel of healthcare stakeholders to develop a list of 28 events that should never happen in health care. These serious reportable events have formed the basis of Minnesota’s Adverse Health Events Reporting Law that was published in 2003. The law requires that hospitals disclose when any of the 28 events occur and requires MDH to publish annual reports of the events by facility, along with an analysis of the events, the corrections implemented by facilities and any recommendations for improvement in Minnesota.

For more information visit the Minnesota Department of Health website.

UK National Reporting and Learning System (NRLS)
In 2005, the National Patient Safety Agency (NPSA) implemented the National Reporting and Learning System. The electronic system relies on data mapping to several commercial databases used by health services across the UK or reporting via a separate e-form to the NPSA.

For more information, visit the National Patient Safety Agency website.22 October, 2008

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