Department of Health

Key messages

  • Every incident reported in the Victorian Health Incident Management System requires a review to identify the most appropriate level of investigation.
  • Incident investigation and management is the responsibility of everyone in a healthcare organisation.
  • All incidents are subject to review irrespective of the incident’s level of severity.

All incidents notified in the Victorian Health Incident Management System (VHIMS) are given an incident severity rating (ISR) on a scale of one to four that guides the level of investigation required.

All incidents undergo a review or investigation irrespective of their severity rating.

There are three levels of investigation:

  • root cause analysis (RCA) - a process analysis that identifies factors that cause adverse events
  • in-depth case review - a detailed and thorough investigation that is less resource-intensive than a root cause analysis
  • local investigation and aggregate review - investigation that is conducted at the local level. Management is responsible for the review. It is conducted when aggregate incident data has identified an issue requiring a quality or practice improvement project.

An RCA investigation is conducted for all sentinel events and ISR 1 clinical incidents where system or process issues directly contributed to the incident outcome.

An in-depth case review occurs for all ISR 1 clinical incidents where the contributing factors relate directly to the patient’s illness or management phase of their chronic illness.

All ISR 2 incidents are investigated using the in-depth case review methodology or principles.

All ISR 3 and 4 incidents are reviewed as an aggregate (as a minimum) over a designated time period (either weekly, monthly or quarterly) as prescribed within the individual health service clinical governance policy and procedures

Health service responsibilities

The effective investigation and management of a clinical incident requires a whole-of-organisation approach with roles and responsibilities clearly understood by everyone in the healthcare team.

Irrespective of an incident’s severity rating or investigation type, clinical risk managers of all health services should ensure:

  • all incidents are assigned appropriate levels of responsibility for investigation and management
  • principles of open disclosure are in place to guide all investigations
  • staff training is in place for investigation of incidents
  • appropriately trained staff members can support other staff involved in incident investigations
  • feedback mechanisms are in place to inform staff of investigation outcomes
  • investigations do not canvass issues of individual performance (questions of individual performance are managed by the organisation’s performance management system).

Reviewed 05 October 2015


Contact details

Postal address: GPO Box 4541, Melbourne VIC 3001

Quality and Safety Branch Department of Health & Human Services

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