SDMS ID: P2010/0285-001 WACSClinProc5.

16/09 Title: Replaces: Description: Target Audience: Key Words: Policy Supported: Purpose: An incident is an unplanned event resulting in or having the potential for injury, ill-health, damage or other loss. It is important for all staff to recognise when an incident has occurred. All staff are required to notify all identified incidents in the Electronic Incident Management System. EIMS notification of the incident should occur as soon as practicable and preferably on the day of the incident. Incident reporting ensures that incidents are managed as and when they occur and assists in preventing recurrence. Reportable Incidents Types Include: Adverse Drug Reaction Incident related to unavoidable, unintended consequence of drug therapy Airway Management Incident related to airway management (i.e. self-extubation) Blood/Blood Product Incident related to the prescribing, processing, dispensing or administration of blood or blood products. Care/Service Coordination Incident related to the communication or coordination of processes between individuals or departments that is not a contributing factor to another incident type (i.e. the patient arrives with chart, etc). Diagnosis/Treatment Incident related to diagnosis or ordering, preparation or performance of a treatment. Diagnostic Test Incident related to ordering, preparation, performance or results of a diagnostic test or exam. Environment Incident related to the internal or external physical environment Fall Incident where an individual makes contact with the ground or an object on the way to the ground. ID/Documentation/Consent Incident related to identification, chart documentation of consent, etc. that is not a contributing factor to another incident.
Maternity EIMS Reportable Incidents May-11 1 WACSClinProc5.16/09

Maternity EIMS Reportable Incidents New guideline Maternity incidents to reported on EIMS Nurses, midwives and medical officers, WACS Electronic Incident Monitoring

Infection Control Incident related to infection control practice and policy (i.e. sharps use, use of personal protective equipment, etc). Lab Specimen/Test Incident related to the order, preparation, performance or results of a lab speciment or test. Line/Tube Incident related to the order, preparation, insertion or use of a line or tube (excluded central, peripheral and PICC lines covered under Vascular Access Device incidents). Maternal/Childbirth Incidents related to the pre-natal, delivery or postpartum care of mother and/or child. Medication/Fluid Incident related to prescribing, processing, dispensing or administration of medication or IV. Nutrition Incident related to nutrition from ordering to administration. Radiation Oncology Incident related to a radiation oncology therapy event. Restraint/Supportive Devices Incident related to use of physical or chemical restraint and supportive devices. Risk Register Entry Any identified risk situation that is not considered an incident or near miss. Safety/Security/Behaviour Incident related to the safety and security of an individual, personal belongings or property or the conduct of an individual. Skin/Tissue Incident related to trauma of skin or tissue such as phlebitis, rashes, etc not resulting from another incident type such as a fall. Surgical Site Infection Incident related to initial diagnosis and tracking of surgical site infection. Vascular Access Device Incident related to complications of central, peripheral and PICC lines. Includes problems/defects in catheters or lines/tubing. Includes all infiltrations and extravasations. Maternity Reportable Incidents Specific incidents that should be reported include: Active 2nd stage delay > 4 hours Antenatal screen test misdiagnosis Apgar score < 7 at five minutes* Baby seizure within first 24 hours of birth Birth trauma to mother during delivery Born before arrival Collapse Cord prolapse Delay / difficulty with resuscitation Eclampsia / convulsion Failed instrument delivery Foetal death in labour Foetal pH < 7.05 cord Foetal pH < 7.20 scalp or lactate > 4.8 scalp* Inappropriate delivery in birthing pool
Maternity EIMS Reportable Incidents May-11 2 WACSClinProc5.16/09

Maternal death Maternal resuscitation Maternal transfer to ICU Medical complication Neonatal death Post-partum haemorrhage Problematic epidural anaesthesia Readmission of baby Readmission of mother Return to birthing suite / OR Shoulder dystocia requiring manoeuvre Stillborn Surgical or anaesthesia complication Third or fourth degree tears Undiagnosed abnormality Undiagnosed breech Undiagnosed pregnancy Unexpected admission to NICU Unexpected childbirth Unplanned home birth Other * Two of LGH maternity reportable incidents are not as they will appear on the EIMS system. Apgar < 7 at five minutes is a current ACHS Obstetric Clinical Indicator. The EIMS system states Apgar < 6 at five minutes rather than <7. Currently the EIMS system does not include scalp Lactate values.

Performance Indicators: Evaluation of compliance with guideline to be achieved through WACS departmental monitoring of EIMS incident reporting. Review Date: Annually verified for currency or as changes occur, and reviewed every 3 years. January 2012. Midwives and medical staff WACS Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Stakeholders: Developed by:

Dr A Dennis Co-Director (Medical) Womens & Childrens Services

Sue McBeath Co-Director (Nursing & Midwifery) Womens & Childrens Services

Date: _________________________

Maternity EIMS Reportable Incidents May-11

WACSClinProc5.16/09