VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS …vhims.riskman.net.au/VHIMS2012docs/VHIMS Incident Review Guide.pdf · VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS Page

VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS

Page 1 Valid for Version 2012 (June) and above – 4 Jun 2012

Introduction

This guide is aimed at Line Managers who are required to

review and investigate incidents reported by their staff.

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

Reviewing Incidents

If you know the ID of the Incident you can use the “Go To”

function to locate the incident

1. Press the icon on the menu or press ALT-G

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

To view an incident from the Entered Incidents page

Click on the Incident ID

1. 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



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

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

Who is Reporting: The details of the staff member who entered

the incident

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

What Happened: Description of the incident. This should be de-

identified 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

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



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)

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 pre-

existing 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.

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

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

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



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/re-

defined/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

a result of the injury

Journals and Actions: Used to enter additional information (file

or progress notes) or to assign or action an allocated task

Press Submit to save changes

Incident Follow-Up (Staff Incidents)

Incident Follow-Up (All Incidents except Staff)

Documents: Used to attach accompanying documents, photos,

correspondence that relates to the incident

Review History: Tells you who has viewed, modified, been

notified of the incident

Recommendations (Mandatory for ISR 1, recommended for

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



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. 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

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

To view the comments click on the <Email> link in the

Review History

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)

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

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



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

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

4. 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

5. Press Add Entry

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



How do I action a Journal?

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. If the list of Journals are collapsed then click on the

Expand icon

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

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

To view an attached document

1. Click on the View button next to the document you

wish to view

2. The Document Review History (viewed by clicking

on the icon next to the respective document)

will display in the Document Details pop-up window

How do you add Recommendations to an

incident?

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

Check the “Have recommendations been made”

field that has been added to the end of Incident

Follow-Up section.

2. 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.



Field Descriptions:

Recommendation #: Describe the recommendation

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

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

Rec # Completed: Enter the date the recommendation has

been completed

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

- 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

To view the Review History of an incident

1. Click on the Flag next to the incident

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

How do I view the changes that have been made

to the incident?

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

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



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

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 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

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

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 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

1. Click on the Record Selector next to the incident

you wish to create a group incident with

2. Press the Make Grouped button

3. 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

4. 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 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 one of the

incidents in the group

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

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