Clinical Incident, Open Disclosure and Complaints Policy

Purpose. This policy sets out how Lakeside Health reports, rates, investigates and learns from clinical incidents and near misses, tells patients when something has gone wrong and manages complaints and feedback.

1.Purpose and scope

Every clinical incident, near miss, hazard and complaint is an opportunity to make care safer. This policy applies to all sites and services and to all staff, students and contractors.

2.Reporting

Any event that caused or could have caused harm to a patient, staff member or visitor must be recorded in the Clinical Incident and Hazard Register before the end of the shift by the person involved or the person who found it. Reporting is expected and will never lead to blame for an honest error. Failing to report is a breach of this policy.

3.Severity rating

Each incident must be rated on the severity assessment scale from 1 (death or permanent harm) to 4 (no harm or near miss). Incidents rated 1 or 2 must be escalated to the Medical Director on the day and investigated with a root cause analysis. Incidents rated 3 or 4 will be reviewed by the department lead and trended.

• Rating 1: death or permanent harm, immediate escalation
• Rating 2: temporary harm needing treatment
• Rating 3: minor harm or discomfort
• Rating 4: no harm, near miss or hazard

4.Open disclosure

When a patient has been harmed, the treating practitioner will tell the patient and their family what happened, apologise, explain what will be done and record the conversation in the patient record. Open disclosure will happen as soon as the patient's condition allows and will not wait for the investigation to finish.

5.Complaints and feedback

Complaints must be acknowledged within two working days and resolved or given a written response within 30 days. The Practice Manager will log every complaint, assign it to the department lead and report themes to the clinical governance committee. Patients will be told how to contact the state health complaints body if they are not satisfied.

6.Learning and review

Investigation findings and actions will be shared with the team involved and, where relevant, at the practice meeting. The clinical governance committee will review incident and complaint trends each month. This policy will be reviewed every two years.