Northern Territory

NTG hospitals use the RiskMan electronic incident management system for clinical incident reporting. RiskMan uses an ISR system to classify clinical incidents. There are five ISR score levels which measure the severity of the impact caused to the person affected following an incident, ISR1 being the highest or most severe (including sentinel events) and ISR5 being the lowest or insignificant (including near misses).

• ISR1 (catastrophic): Death or permanent loss or reduction of functioning and recovery is unlikely. Includes sentinel events.
• ISR2 (major): Significant harm or impact. Loss or reduction in functioning is temporary and full recovery is expected.
• ISR3 (moderate): Harm which may require a higher level of care or observation. No loss or reduction in function.
• ISR4 (minor): Harm is minimal. Additional level of care not required.
• ISR5 (insignificant): No harm. Includes near misses.

NTG hospitals also participate in the STIR Program for national haemovigilance reporting. Table 45 shows how the NT ISR system aligns with the clinical outcome severity defined in the ANHDD.

Reporting requirements for ISR incidents

ISR1: Catastrophic incidents including sentinel events

For both ISR1 and sentinel events, the Department of Health's Clinical Safety & Quality Branch must be notified as soon as practicable or at least within three days of the incident being identified.

All ISR1 incidents must be reviewed by the organisation to determine opportunities for system improvement. On identification of an ISR1 incident, a review using an appropriate methodology such as RCA is undertaken to explore causation and identify contributing factors, and the following notifications are made:

• The Chief Operating Officer/Executive Director commissions the RCA team and the review terms of reference.
• The summary report of the analysis is presented to the team involved with care of the patient. The outcomes are also presented or made available at relevant staff meetings to ensure staff are aware of the factors contributing to the incident and the action being taken to improve safety.
• The final de-identified RCA summary report is to be provided to the Clinical Safety & Quality Branch within 60 calendar days of notification.
• Recommendations from the RCA report are linked to the health service's risk register. This ensures continuity of monitoring of both the evaluation and effectiveness of the recommended actions as a corporate risk management strategy.

ISR2 incidents

All ISR2 incidents require a detailed analysis of the incident using an appropriate methodology such as in-depth case review, or a modified version of RCA. Responsibility for reporting ISR2 incident reviews is assigned to a designated senior manager in order to link into the health service safety and quality governance policies and procedures. All complete ISR2 case reviews must be submitted to the organisation's safety and quality committee for consideration.

ISR3, ISR4 and ISR5 incidents

The analysis of ISR3, ISR4 and ISR5 incidents can be undertaken at the local level but management responsibility for the analysis or review process must be assigned.