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It provides practical guidance and templates for clinicians and managers to understand, undertake, and use health data to improve safety and quality. The toolkit explains key steps from immediate action and notification through prioritisation using Severity Assessment Codes (SAC), investigation and reporting, to recommendations, implementation, monitoring, and evaluation.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/clinical-incident-management-toolkit-department-of-health-2011/665402/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/clinical-incident-management-toolkit-department-of-health-2011/665402.png","ImageObject",300,407,{"name":92,"@type":93},"Dusta123","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-10-29",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of the Clinical Incident Management (CIM) Toolkit?","Question",{"text":112,"@type":113},"It helps WA Health staff manage clinical incidents according to CIM Policy. It provides practical advice and resources to understand, undertake, and use health data to improve safety and quality of care.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What core steps does the toolkit cover for managing a clinical incident?",{"text":117,"@type":113},"It covers immediate action, notification and initial review, prioritisation using Severity Assessment Codes (SAC), investigation and analysis, reporting, feedback, and the full recommendations lifecycle including implementation, monitoring, and evaluation.",{"name":119,"@type":110,"acceptedAnswer":120},"How does the toolkit support investigation of major clinical incidents?",{"text":121,"@type":113},"It outlines investigation methods and tools such as Root Cause Analysis, London Protocol, HEAPS, Five Whys, Health Record Review, and FMEA. It also provides major incident templates, including information logs, interview sheets, narratives, contributory factors statements, and risk ratings.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},665402,1793302398,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":14,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":129,"read_time":144},962093541925,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","Clinical Incident Management Toolkit  \nDepartment of Health 2011  \nAcknowledgements  \nThe Patient Safety Directorate (PSD) acknowledges and appreciates the input of all individuals and groups who have contributed to the development of this policy toolkit.  \nIn particular, the PSD would like to recognise the valuable contribution made by members of the South Metropolitan Area Health Service Safety, Quality and Performance Unit who developed section four of this document: Major Clinical Incident Investigation Processes/Tools.  \nClinical Incident Management Toolkit 2011  \nThe Clinical Incident Management Toolkit may be updated at regular intervals. For the latest version of this document, please visit: [http://www.safetyandquality.health.wa.gov.au](http://www.safetyandquality.health.wa.gov.au)  \n[The Clinical Incident Management Toolkit is protected by copyright. Copyright resides with the](The Clinical Incident Management Toolkit is protected by copyright. Copyright resides with the)[ ](The Clinical Incident Management Toolkit is protected by copyright. Copyright resides with the)[State of Western Australia. This toolkit may be published or reproduced but not altered in any](State of Western Australia. This toolkit may be published or reproduced but not altered in any)[way](way), unless permission from the PSD, Department of Health has been given.  \nFor further details please contact:  \nPatient Safety Directorate  \nPerformance Activity and Quality Division Western Australian Department of Health  \n189 Royal Street, EAST PERTH Western Australia 6004  \nTel: (08) 9222 4080  \nFax: (08) 9222 2032  \nEmail: [safetyandquality@health.wa.gov.au](safetyandquality@health.wa.gov.au)  \nWebsite: [http://www.safetyandquality.health.wa.gov.au](http://www.safetyandquality.health.wa.gov.au)  \nDisclaimer  \nAll information and content in this material is provided in good faith by the WA Department of Health, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents, do not accept legal liability or responsibility for the material, or any consequences from its use.  \nClinical Incident Management Toolkit | Department of Health 2011  \nContents  \n1. Introduction and background 1  \n2. Managing a clinical incident 3  \n2.1 Overview of key steps to managing a clinical incident 4  \n2.2 Detailed steps in managing a clinical incident 5  \n2.2.1 Immediate action 5  \n2.2.2 Notification and initial review of a clinical incident 5  \n2.2.3 Prioritisation of investigation using Severity Assessment Codes (SAC) 5  \n2.2.4 Understanding SAC 1 clinical incidents-Sentinel Events 7  \n2.2.5 Investigation of all SAC 1 clinical incidents for both public and private hospitals and non-government organisations 7  \n2.2.6 Analysis and investigation 11  \n2.2.7 Clinical incidents across health service/provider boundaries 11  \n2.2.8 Reporting 12  \n2.2.9 Feedback 12  \n2.2.10 Recommendations 12  \n2.2.11 Implementation of recommendations 13  \n2.2.12 Monitoring of recommendations 13  \n2.2.13 Evaluation of recommendations 13  \n2.2.14 Transfer of clinical incident (AIMS) forms 13  \n2.2.15 Retention and disposal of clinical incident forms 13  \n3. Overview of clinical incident investigation methods and tools 14  \n3.1 Root Cause Analysis 14  \n3.2 London Protocol 17  \n3.3 Human Error and Patient Safety (HEAPS) incident analysis tool 17  \n3.4 Five Whys 17  \n3.5 Health Record Review 18  \n3.6 Failure Modes and Effects Analysis (FMEA) 18  \n3.7 Clinical risk management 18  \n4. Major clinical incident investigation process/tools 19  \n4.1 Major clinical incident templates 28  \n4.1.1 Information log 28  \n4.1.2 Information sheet for interviews 29  \n4.1.3 Narrative of steps – The story 36  \n4.1.4 Contributory factors statement 38  \n4.1.5 Investigation recommendations summary 43  \n4.1.6 Clinical risk rating 44  \n4.1.7 Recommendations follow up memo 48  \ni  \nClinica","cbCaic8E2H0NNzqv","https://ap.wps.com/l/cbCaic8E2H0NNzqv","pdf",2518745,94,"English","# Introduction and background\n## Managing a clinical incident\n## Overview of clinical incident investigation methods and tools\n## Major clinical incident investigation process/tools\n## Models of feedback\n## References\n## Appendices","[{\"question\":\"What is the purpose of the Clinical Incident Management (CIM) Toolkit?\",\"answer\":\"It helps WA Health staff manage clinical incidents according to CIM Policy. It provides practical advice and resources to understand, undertake, and use health data to improve safety and quality of care.\"},{\"question\":\"What core steps does the toolkit cover for managing a clinical incident?\",\"answer\":\"It covers immediate action, notification and initial review, prioritisation using Severity Assessment Codes (SAC), investigation and analysis, reporting, feedback, and the full recommendations lifecycle including implementation, monitoring, and evaluation.\"},{\"question\":\"How does the toolkit support investigation of major clinical incidents?\",\"answer\":\"It outlines investigation methods and tools such as Root Cause Analysis, London Protocol, HEAPS, Five Whys, Health Record Review, and FMEA. It also provides major incident templates, including information logs, interview sheets, narratives, contributory factors statements, and risk ratings.\"}]","Clinical Incident Management Toolkit - Department of Health 2011 | PDF",237]