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Reporting requirements on incidents and adverse events
The department has funding, program and/or regulatory responsibility for a wide range of health services. Sometimes incidents and adverse events may occur in the delivery of these services. Understanding when these occur, and the circumstances surrounding them, can assist with ultimately improving the quality of services provided into the future.
A range of incident reporting requirements are in place across the department. These reporting requirements vary depending on the type of incident and the services involved, which in some instances are underpinned by legislation or national agreements.
The following table summarises the reporting requirements, and further information can be found by following links to relevant websites and policy resources.
| Departmental reporting process, policy or guideline | Scope | Description |
|---|---|---|
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This departmental instruction, released in October 2010, sets out the management and reporting requirements for incidents involving clients or staff in Department of Health-funded community service organisations (CSOs). To accommodate the diversity of services within scope of this instruction, the department will issue supplementary guidelines for: |
|
Reportable deaths in psychiatric services |
Psychiatric services, defined by the Mental Heath Act as:
This definition includes private mental health care facilities licensed to perform ECT and Psychiatric Disability and Rehabilitation Support Services (PDRSS) and funded agencies providing services to individuals with a mental disorder. |
Under the Mental Health Act 1986 (the Act) an authorised psychiatrist of an approved mental health service or a person in charge of any other ‘psychiatric service’ must report the death of any person receiving treatment or care for a mental disorder, which is a reportable death within the meaning of the Coroners Act 2008. The Chief Psychiatrist’s reportable deaths guideline also requires that services report the death of any currently registered mental health consumer if it is unnatural or unexpected, and where they become aware of the unexpected death of a consumer who was a registered client within the preceding six months. The Chief Psychiatrist reviews the report to identify any clinical, service or system issues of concern.
|
Public mental health services |
Section 105 of the Act established the appointment of a Chief Psychiatrist who has responsibility under the Act for the medical care and welfare of persons receiving treatment or care for a mental illness. The Chief Psychiatrist's responsibilities include monitoring the clinical standards of psychiatric practice and treatment provided by public mental health services, and responding to complaints from consumers, carers and others. For further information about the role of the Chief Psychiatrist, and guidelines to inform mental health practitioners and services about the operation and clinical issues in relation to the Mental Health Act see Office of the Chief Psychiatrist |
|
Public sector residential aged care services (PSRACS) |
Under the Commonwealth Aged Care Act, all Commonwealth funded residential aged care services (including the 196 services operated by Victorian public entities) are required to report any instances where there are allegations of unlawful sexual contact, use of excessive force, or missing residents to the Commonwealth Department of Health and Ageing (DoHA). The Department of Health requires Victorian public sector residential aged care service providers to report these to it at the same time as they are reported to DoHA. Further details are set out in Hospital Circular 18/2007 (August 2007), and the reporting form developed by the department for this purpose, the PSRACS Alleged or Suspected Physical Assault or Sexual Assault online reporting form. |
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Victorian Health Incident Management System See: |
All Victorian publically-funded health services are within scope and include:
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The Victorian health incident management policy outlines the management and reporting requirements for clinical (patient) incidents in public funded health services and agencies. The department’s Sentinel Event Program is incorporated in the VHIMS data collection. See information relating to sentinel events and the department's Root Cause Analysis program In scope incidents are reported through the Victorian health incident management system (VHIMS). VHIMS is a statewide incident management system based on a standardised incident data set. The primary aim of VHIMS is improving quality through incident management. The VHIMS also provides the vehicle for collecting data in relation to :
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Public and private health services outside VHIMS scope |
The Blood Matters Serious Transfusion Incidents Reporting System (STIR) is a central reporting system for serious adverse events with transfusion of blood or blood components including near-miss incidents. STIR notifications are included in VHIMS. See additional reporting requirements for STIR |
|
Radiation practices |
The Radiation Act 2005, which is administered by the Department’s Radiation Safety Team, creates a licensing framework for the use of radiation and the conduct of radiation practices. A condition of all management licences authorising the conduct of radiation practices requires mandatory reporting of radiation incidents to the Department. This obligation applies equally to the public and private sector. Incidents are reported annually in the Department’s Annual Report relating to the administration of the Radiation Act. See further information about management licences relating to radiation practices. |
Note:
This list is an indication only of the range of incident reporting frameworks and obligations instigated by the Department of Health and services should be familiar with the requirements set out in departmental service agreements.
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