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SOP2013-003
12/381 (D13/1482)
Date issued
23 January 2013
Contents
Policy Statement
Author Branch
Branch Contact
Division
Clinical Governance
Patient Safety
Clinical Governance
Summary
Applies to
All NSW Ambulance staff including paramedics, patient transport officers, doctors,
nurses, volunteers, and corporate staff
Review Date
Previous Reference
Status
Approved by
15 January 2015
SOP2008-038
Active
Chief Executive
Related Documents
Revision History
Version (Circular #)
Amendment notes
23 January 2013
(SOP2013-003)
12 December 2008
(SOP2008-038)
SOP2013 -003
Page 1 of 4
INTRODUCTION
A Variation to Clinical Practice (VCP) is defined as any clinical intervention undertaken that is not consistent
with current NSW Ambulance protocols, pharmacology, skills or procedures.
Variations occur for a number of reasons, however in all cases it is recommended that they are reported and
measured against the best available evidence as documented in agreed clinical practice guidelines. Variations
include cases where a paramedic decides in the patients best interest, to work outside authorised clinical
practice, protocols, and cases where an inadvertent mistake was made.
A variation does not necessarily equate with an error nor does the reporting of a variation imply permission to
act outside authorised clinical skill levels or to vary practice beyond recommended protocol.
To enable supported Open Disclosure paramedics are required to report the incident to the Duty Operations
Manager (DOM) when an error has occurred. Refer to Figure 1 on page 4.
NSW Ambulance acknowledges that variations will occur on occasion and supports the development of a
culture and environment wherein all clinicians are encouraged to recognise and promote patient safety through
the identification of opportunities to review and improve clinical practice that may arise by reporting these
variations.
The purpose of this policy is to ensure that a just culture prevails in the management of variations, and that
NSW Ambulance provides support for paramedics where a variation or error has occurred.
CLINICAL REVIEW
The primary purpose of a clinical review is to ensure that patients receive care consistent with best practice.
The Clinical Review Group (CRG) reviews all variations with the focus being on the clinical aspects of the
case, with each incident assessed on its own merit. The Clinical Governance Staff Specialist and Manager
Patient Safety jointly chair the CRG. Members of the CRG are bound by a confidentiality clause included
within the Terms of Reference.
Clinical reviews are a quality improvement process that seeks to improve patient care and outcomes through a
systemic review of care against clinical protocols and best practice. Additionally, clinical reviews assist in
identifying trends in clinical practice that inform the development of clinical protocols.
SOP2013 -003
Page 2 of 4
INCIDENT REFERRALS
In addition to VCPs, managers can refer incidents to the CRG requesting a determination on clinical aspects of
an incident, which is as a result of a clinical record audit or to support investigations. An incident referred to the
CRG must be accompanied by a briefing note or provide detail on why the incident has been referred for
clinical review.
Note:
Referrals to the CRG must include supporting documentation e.g. clinical record/s and initial fact finding notes.
OUTCOME OF REVIEWS
The CRG will write to the notifier advising of the review outcome with specific feedback according to the type
of variation and any associated support recommendations.
To maintain confidentiality, the review findings are conveyed only to the notifier, irrespective of whether the
case is self-reported or reported by another party.
CLINICAL GOVERNANCE
The CRG provides a de-identified report detailing the categorisation of variations, associated trends and
recommended actions to the Clinical Governance Committee through the Executive Director Clinical
Governance.
For more information or if you have any questions regarding the variation to clinical practice process or
reporting variations contact the Patient Safety Manager on 9779 3824 or email your comments to
ClinicalReview@ambulance.nsw.gov.au.
SOP2013 -003
Page 3 of 4
Yes
Was it an error?
Yes
Or
Email
clinical@ambulance.nsw.gov.au
Or
No
Documentation
Complete an IIMS, (IIMS is located on
the ASNSW intranet home page) using
the Clinical subgroup within the Incident
Notification Category. Once the IIMS has
opened select Variation to Clinical
Practice within the Incident
Monitoring>Australia>New South Wales
subgroup
Review
All VCPs are reviewed by the Clinical Review
Group (CRG) who assess each VCP on its
own merit taking into account improvements
in patient safety and clinical quality
SOP2013 -003
Page 4 of 4