VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS Introduction
To view an incident from the Entered Incidents page
This guide is aimed at Line Managers who are required to review and investigate incidents reported by their staff.
Click on the Incident ID
Role of the Line Manager
When an incident is entered by a staff member reporting to you, you will be notified via email. You can either Click on the link in the email to open the incident or From the menu select My Workspace -> Review My -> Incidents. This will display a list of incidents entered by you; your staff; or those that you have been granted permission to via an alert, distribution list or a Journal Review the detail of the Incident Check the Review History to see who else is aware of the incident Create a Distribution List if others need to be informed of the incident Optional: Bookmark the incident if you wish to enable a quick return to the incident Check consistencies of classifications eg. Primary & Related Incident Types; Remove any inappropriate statements or unfounded allegations as organisational policy may dictate Submit any details that need immediate change Investigate the Incident Return to the Incident (via Bookmark or Entered Incidents page) Update Findings eg. Severity, Investigation/Findings, Journals, attach relevant files. If the Incident has a Severity of 1 or 2 ensure the respective fields are completed eg. Activity/procedure Description; Controls to prevent re-Occurrence Complete the Incident Remove the Bookmark, if applicable Ensure Journals are actioned as required Optional: Mark Incident as Finalized
1.
Reviewing Incidents If you know the ID of the Incident you can use the “Go To” function to locate the incident 1.
Press the
1.
Select Item = Incident and enter the ID
2.
Press Enter or the Go button
3.
If you have permission to the incident it will open
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icon on the menu or press ALT-G
Review the Incident and investigate as required
Fields displayed in yellow are mandatory and must be completed before saving the incident
If the incident involves more than one person and a grouped incident has been created, click on the respective ID to view the other incidents grouped with this incident. Each grouped incident needs to be reviewed and submitted separately
The Review History at the bottom of the incident will indicate to you who has been notified of, edited or viewed the incident. If required create a distribution list to notify other users of the incident
2.
If changes are made to the incident press the Submit button at the bottom of the incident
3.
The changes will be visible to all authorised users and the original version of the incident will remain intact
Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS Example of reviewing an incident Note: The field descriptions in red denote those fields the Line Manager would need to complete depending on the severity of the incident. These fields will depend on the template setup in your organisation Control Panel: Allows you to print a copy of the Incident, distribute the incident to other users as required, view the history of the changes to the incident by clicking on the Change History button, view any grouped incidents by clicking the respective ID under the Related Incidents heading. Optionally Bookmark the incident for future follow-up Notification Type: Type of incident that was entered Lodgement Method: Method by which the incident was lodged Source of Notification: Where did the incident originate For organisations that need to report Category 1 & 2 incidents to the Dept of Human Services/Dept of Health Department Critical Incident: If Yes check this field Critical Incident Category: Specify the category of the critical incident 1, 2 or 3 Critical Incident Category Description: Select a suitable description of this critical incident from the list Note: A specific DHS Report can be generated from VHIMS on Posted Incidents. This would be done by the Risk/Quality Mgr
Who is Reporting: The details of the staff member who entered the incident
Who Was Affected: The details of who or what was involved in the Incident. Person Identifier Type: How the person affected can be identified Person Identifier: Where the incident is a Clinical Incident, this would be the patient/client/resident’s UR Number. For OHS incidents this identifier (if known/used) could contain Contractor Registration No, employee number
What Happened: Description of the incident. This should be deidentified where possible. Note - The Summary and in some cases the Details will be transmitted to the Dept of Health and VMIA where applicable Service Being Provided: The nominated DH specific health services that were being undertaken at the time of the incident Activity/Procedure Description (Mandatory for ISR or 2): Brief description of the activity or procedure that took place at the time of the incident eg. Administering a specific drug Activity Procedure Type (Mandatory for ISR or 2): The DH specific activity/procedure classifications that was undertaken for the patient/client/resident at the time of the incident. Immediate Actions Taken: Brief description of the actions/interventions undertaken immediately after the incident to minimise harm and make the situation safe Post Intervention Codes (Mandatory for ISR 1 or 2): The DH specific intervention classifications taken by staff to minimise harm following an incident eg. Assessment, Consultation, Interview, treatment Transferred to Alternate Service Provider/Facility (Mandatory for ISR 1 or 2): The patient/client/resident was transferred to an alternative health service as a consequence of the incident. Only select “Yes” if the patient is transferred out of your facility to another facility. Do not select if the patient was transferred internally Page 2
Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS When did the incident occur: The date and time of the incident or when the e incident vent was discovered (eg. hazard). Start of Incident Time Band/End of Incident Time Band: These fields will default to an hourly time range depending on the entered Incident Time Duration of Incident: The length of time the incident has occurred eg. medicine administered incorrectly over 3 days. In most cases this will be set as “Less than 1 day” Number of occurrences: The number of times the incident has occurred over the duration of the incident eg. administered wrong medicine 6 times over 3 days. In most cases this will be set as 1 Where did the incident occur: Details on where the incident occurred including the address and post code and the Dept/Unit or Program responsible for the incident Physical Setting: This is the DH specific location list Others Involved: Names of any witnesses or others involved in the incident How is it Classified: The Primary (main) incident type eg. Fall and any related incident types (suggested max of 2), Fracture based on the description of the incident. If Slip/Trip/Fall, Pressure Ulcer or Behaviour/Towards Others classifications are selected additional extensions will display Specific Incident Class: A DH specific list of agents that may have been involved in the incident eg. blood, medicines, radiation, equipment. If none of the specific agents are applicable select “Other”. Additional Extensions will display dependent on the selected classes (agents)
Slip/Trip/Falls Extension: In this example the Primary Incident Type = Slip/Trip/Falls. Additional information relating to the slip/trip/fall will be displayed
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Incident Assessment: Actual Severity: What was the severity of the incident? This will be derived from a set of 3 questions. Nature of Harm (Mandatory for ISR 1 only): If the Degree of Impact involves harm or death and the incident is an ISR 1, describe the nature of harm Organisational Severity: What impact did this incident have only the organisation Overall Severity will be auto-selected based on the more severe – Actual Severity or Organisational Severity Description of Possible Contributing Factors: Description of possible contributing factors - investigation would be required Contributing Factors Identified (Mandatory for ISR or 2): Select Yes or No Contributing Factors (Mandatory for ISR 1 or 2): If there are known contributing factors select from the DH specific classifications Contributing Factory Summary (Mandatory for ISR 1 or 2): Summarise the identified contributing factors (if identified) Likely that Pre-existing Conditions had Significant Impact (Mandatory for ISR 1 or 2): Normally done after a Root Cause Analysis (RCA) or Case review, when it is determined preexisting health conditions significantly impacted the outcome of the incident for the persons impacted. Pre-existing Health Conditions/Problems (Mandatory for ISR 1 or 2): Enter a brief description of these pre-existing conditions if the pre-existing conditions did have a significant impact on the incident. Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS Incident Follow-Up (All Incidents except Staff)
Incident Follow-Up (Staff Incidents)
Incident Follow-up: This section allows you to enter information relating to the investigation of the incident Description of Preventative Factors (Mandatory for ISR 1 or 2): Describe the preventative factors that are currently in place to prevent this type of incident from occurring. Preventative Factors (Mandatory for ISR 1 or 2): Select the preventative factors that are in place and whether they were successful or unsuccessful in the case of this incident from the DH specific classification set Controls to Prevent Recurrence: Specify the controls that have been implemented to prevent the re-occurrence and minimise the harm caused by similar incidents from the DH specific classification set Specific Details of Control/Changes Made: Enter a brief description of the implemented controls Proposed Preventative Actions (Staff Incidents Only): Select one or more proposed corrective actions that will be introduced/re-defined/changed as a result of incident Preventative Actions (Staff Incidents Only): Select one or more corrective actions that have been introduced/redefined/changed as a result of incident. Internal Reviews (Mandatory for ISR 1 or 2): Select the investigation process from the DH specific classification set eg. If a routine investigation, select Line Manager Review Discussed with Subject/Carer (Mandatory for ISR 1 or 2): For clinical incidents only, specify if the incident was discussed with the health care recipient or their carer in accordance with open disclosure principles Have recommendations been made (Mandatory for ISR 1, recommended for ISR 2): If checked the “Recommendations” section will display allowing managers to specify any recommendations as a result of investigating the incident For Staff: If the staff had an injury specify Nature of Injury: Select the type of injury Agency of Injury/disease: What caused the injury to occur Mechanism of Injury: How did the injury occur Regardless of whether the staff member had an injury or not specify Shift Arrangements: What shift was the staff member working Proportion of Shift Worked: How much of the shift did the staff member work before the incident Training Provided: What sort of training has been provided for this staff member Time Lost from Work: Will there be any time lost from work as Recommendations (Mandatory for ISR 1, recommended for a result of the injury ISR 2): Used to add and assign recommendations as part of the RCA or Case review process for ISR 1 and 2 incidents. Up to 8 recommendations can be entered. A new set of Recommendation fields will be added each time you enter data into the Recommendation # field
Journals and Actions: Used to enter additional information (file or progress notes) or to assign or action an allocated task
Documents: Used to attach accompanying documents, photos, correspondence that relates to the incident
Press Submit to save changes
Review History: Tells you who has viewed, modified, been notified of the incident
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Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS How do I let others know of the incident? If, after reading the incident and looking at the Review History, you think other users within your organisation should be notified of the incident, you can create a Distribution List To create a distribution list 1.
Click on the Dist List button
2.
Search for the users using the Filter List option
3.
Highlight the user in the Unassigned List and press Assign
4.
Repeat above steps if more users are to be notified
5.
Recommended: Enter a comment explaining why the selected users are being distributed the incident. These comments will appear on the email that is sent to the nominated users and can also be accessed from the Review History of the Incident
6.
What happens when you are distributed an Incident? 1.
If you have an email address in your User profile you will be sent an email notification with a link to the incident
2.
If you have unread distributed incidents An Incident For Review message will appear at the top of your VHIMS system (see example below)
Press Send Email & Close
Note: If there are already users in the Assigned list when you are creating a Distribution list, it means that the users have not yet read the incident – do not delete them from the list, as this could negate their permissions to the incident. Only the newly added users will receive the email
When you click on the link it will take you to the Assigned Incident - Unviewed Listing page. You can open the incident from this page by clicking on the Incident ID.
Once you have read all your distributed incidents the “Incident review required” message will disappear
What is the “Bookmark” function? Bookmarking places the incident into your Bookmark Items list available on your My Workspace -> Reminders & Alerts page. You may wish to bookmark (flag) the incident as one you would like to follow-up later or requires further information before investigations are underway. To bookmark an incident, click on the Bookmark button
Can I view the comments sent in a Distribution List? The Comments included in a distribution list email can be viewed by the sender/receiver via the Review History of the Incident
How do I view my bookmarked incidents? All your bookmarked Incidents will be listed in your Bookmarked Items list under the My Workspace -> Reminders & Alerts page 1.
To open the Incident, click the Notification Date link
2.
To remove the bookmark, click on the Bookmark button on the Control Panel
To view the comments click on the link in the Review History
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Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS 4.
What does the “Alert Me” function do? The “Alert Me” function, when activated, will notify you of any changes to the incident (except changes to the Journals and Documents). 1.
To setup a Personal Alert click on the Alert Me button
2.
Select if you want the Personal Alert to be based on changes to unposted and/or posted incidents
3.
Press Save
5.
If you are assigning a task
Enter a due date or select the date using the date picker in the Followed up Date field
Assign a user in the Follow-up allocated to field - press the Filter button and search for the user. You will need to select the user from the Follow-up Allocated To field once you have used the filter option
Press Add Entry
Can I print a copy of the incident? A copy of the current version of the incident can be printed from an opened incident in different formats eg. Word™, PDF, Excel™ 1.
Select an output format from the list
2.
Press Print
How do I add a Progress/File Notes or assign a task? Journals are used add progress/file notes and can also be used to assign a task or action or another VHIMS User. When you assign an action or task, the assigned user will be sent an email notification with details of the task and a link to the Incident To add a Journal 1.
Press Add New Journal Entry
2.
Select a Journal Type from the list
3.
Enter a description
6.
If the journal is not allocated to a user, it will automatically be actioned once the incident is saved
7.
If the Journal is allocated to a user, once the incident is submitted an email notification will be sent to the allocated user with details of the Journal and a link to the incident
8.
If the Journal is not actioned by the due date then an email reminder will be sent to the allocated user as well as yourself
How can I view a list of outstanding tasks assigned to me? If you have been assigned a task via the Journals, all your un-actioned Journals will be listed in your Allocated Journal Actions list under the My Workspace -> Reminders & Alerts page 1.
Click on the Created date link to open the Incident
2.
Once you have actioned the Journal it will be removed from this list
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Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS How do I action a Journal?
To view an attached document
If a Journal is assigned to you, to ensure the creator of the journal knows that you have completed the task, the Journal should be actioned
1.
Click on the View button next to the document you wish to view
2.
The Document Review History (viewed by clicking
1.
If the list of Journals are collapsed then click on the Expand icon
on the icon next to the respective document) will display in the Document Details pop-up window
2.
Click on the Action button on the relevant Journal
3.
Press Yes in the pop-up message
4.
If required add another Journal to enter additional comments that relate to the actioned Journal
5.
Submit the incident to update your changes
How do you add Recommendations to an incident?
Can I attach a file to an Incident? Relevant files of any description eg. documents, photos can be attached to an Incident via the Documents section 1.
Press the Add Document button
2.
Enter a description of the file
3.
Press Browse to locate the file
4.
Once selected press Add
5.
Repeat steps 1-4 if more files need to be attached
1.
Press Close
At each organisation, the Department of Health would expect that recommendations will be made following investigations of incidents with a severity rating of 1 or 2. Note: It is mandatory to have at least one recommendation if the Incident has a Severity = 1 and only recommended if the incident has a Severity = 2
1.
To add a recommendation
2.
Check the “Have recommendations been made” field that has been added to the end of Incident Follow-Up section.
Up to 8 recommendations can be added.
Once you enter details of the recommendation in the Recommendation # field and tab out, a new set of Recommendation related fields will display, and so on.
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Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS Field Descriptions:
To view the Review History of an incident
Recommendation #: Describe the recommendation
1.
Click on the Flag next to the incident
Responsibility for Rec #: Click on the filter icon to search for the user who will be responsible for this recommendation. Once filtered select the user in the Responsibility for Rec # field
2.
The Review History will display. This information will enable you to see if there were amendments made to the Incident that you were perhaps waiting on
Rec # Project Code: Nominate a project number for this recommendation Rec # Status: Specify the status of the recommendation eg. proposed, closed, ... Rec # Role Assign ID: This is any unique identifier for the person who has been assigned to the recommendation eg. staff members name, Staff ID Rec # Role Assign: Select the role of the person who has been assigned this recommendation by clicking this button and selecting from the VHIMS Classification Selector (this is the same list as the Reporter’s Role list). Rec # Due Date: Enter the date the recommendation should be completed
How do I view the changes that have been made to the incident?
Rec # Completed: Enter the date the recommendation has been completed
Each time a change is made to an incident another version of the incident is created; this ensures the original version is kept intact. The incident you are viewing is the most current version
Rec # Outcomes: Describe the outcome of the recommendations Rec # Hierarchy Control: Based on the recommendations select the control (only one control can be selected) that may prevent future occurrence of this type of incident Note: # = Number of the recommendation
How do I know which incidents I have viewed and those that have been modified since I last viewed them? Next to each incident on your incident list there is a coloured flag which represents your viewing status of your incidents
1.
Click on the Change History button in the Control Panel of the opened Incident
2.
The Incident Edit History window will open displaying the changes by version or by field . You will only be able to view the changes on fields that you have permission to view in the Incident Note: The Incident Edit History will not display any changes to Journals or Document as there is no history. Only the current versions of the Journals and Documents are available on any version of an Incident
- You have viewed the incident and there have been no modifications - There have been modifications (including journals) since you last viewed the incident - You have not yet viewed this incident
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Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS If I have finished working on an incident, how do I hide it from my Incident List? If you have completed your investigations and no longer require the incident to be shown in your “Entered Incidents” list, you can “Finalize” the Incident, either from an opened incident or from your Entered Incidents page To finalize an Incident from an opened Incident 1.
Click on the Finalize button
2.
Once finalized a tick will display next to this button, an entry will be added to the Review History of the incident and it will be hidden from your Entered Incidents list
Note: You can remove the finalized flag by checking the incident and pressing the Finalize button. The entry in the review history will also be removed
What is a Grouped Incident? A grouped incident is one involving more than one person in the same event eg. An aggression incident Grouped incidents can be created 3 ways 1.
After the first incident is submitted, by clicking on the “Click here to create a grouped incident” button on the Incident Confirmation page
2.
From the “Entered Incidents” page by checking the incident you wish to group from, and pressing the “Make Grouped” button which will open a copy of the incident
3.
If the incidents were entered separately they can be grouped together using the “Group Incidents” function on the “Entered Incidents” page
To finalize Incidents from your Entered Incidents page 1.
Check mark the incident(s) that you would like finalized
2.
Press Finalize . The incident(s) will be hidden from your Entered Incidents List
How can I tell if an incident has been grouped? To identify an incident is part of a grouped incident you will need to show the “Group” column on your Entered Incidents list 1.
Press the Change Columns button
2.
Check mark “Show” next to the Group Column Label
3.
Optional: Change the Sort Order
4.
Press Close (at the bottom of the Change Columns window)
How do I view an incident I have finalised? 1.
On the Entered Incidents page, check Show Finalized
2.
Press Change View
3.
A Finalized column will display, indicating which incidents have been finalized. Finalized incidents can still be opened and modified if required
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Valid for Version 2012 (June) and above – 4 Jun 2012
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS How do I create a new grouped incident from an existing incident? If you need to create a grouped incident from an existing incident, this can be done from your Entered Incidents page
How do I dissolve a set of grouped incidents? In some cases, users will group incidents that should not have been grouped eg. A resident has had 3 falls in the one day but they all occurred at different times
1.
Click on the Record Selector next to the incident you wish to create a group incident with
1.
Click on the Record Selector next to one of the incidents in the group
2.
Press the Make Grouped button
2.
Press the Group Incidents button
3.
Either press Exclude next to the incident that needs to be removed or press Dissolve Group if you wish to dissolve the entire grouping
4.
Press Close
3.
4.
A copy of the incident will open with some fields/sections cleared eg. “Who Was Affected” section and the Severity of the Incident. Make any changes to the incident as required and press Submit If you then need to create another grouped incident after submitting the incident press the “Click here to create a grouped incident” button on the Incident Confirmation page
How do I group 2 or more incidents together? If you find that 2 or more incidents should have been grouped but were not 1.
Click on the Record Selector next to the incident you wish to group to
2.
Press the Group Incidents button
3.
Enter the ID of the incident you wish to group with the selected incident and press Add Group
4.
Repeat step 3 if more incidents are to be grouped
5.
Click on the Promote to Master button next to the incident that will be the master incident
6.
Press Close
How do I check that I have the right staff reporting to me? Refer to the Manager/Staff Relationships Guide accessible via the menu Help -> VHIMS Quick Guides -> Manager/Staff Relationships Guide
What happens if I go on Leave? Refer to the Personal Delegates Guide accessible via the menu Help -> VHIMS Quick Guides -> Personal Delegates Guide
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Valid for Version 2012 (June) and above – 4 Jun 2012
