VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS …vhims.riskman.net.au/VHIMS2012docs/VHIMS...
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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
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS
Page 2 Valid for Version 2012 (June) and above – 4 Jun 2012
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
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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
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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
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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
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS
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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
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS
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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.
VHIMS QUICK REFERENCE GUIDE TO REVIEWING INCIDENTS
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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
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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)
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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