On 1 July 2012, we expanded our approach to reportable events monitoring.
Reportable events monitoring applies to the following healthcare providers:
- public sector health service facilities
- private health facilities and
- the Queensland Ambulance Service.
Most healthcare delivered in Queensland’s public and private health facilities and during the provision of ambulance services is safe and effective. Occasionally unforeseen and serious events occur where patients are harmed or unexpectedly die while receiving healthcare. These are known as ‘reportable events’. Reportable events are defined at section 29
of the Hospital and Health Boards Regulation 2012
and at section 36A
of the Ambulance Service Act 1991.
From 1 July 2012, we will monitor all reportable events that occur, not only those reportable events for which healthcare providers conduct a root cause analysis (RCA), as has been our practice to date.
An RCA is a systematic process of analysing reportable events to identify:
- factors that contributed to the event
- remedial measures that could be implemented to prevent a recurrence of a similar event.
However, an RCA of a reportable event does not include:
- investigating the professional competence of a person in relation to the event
- apportioning blame.
What information does the HQCC require for reportable events?
When to send an RCA report
When an RCA has been conducted and completed, healthcare providers are required (pursuant to section 108 of the Hospital and Health Boards Act 2011 or section 36O of the Ambulance Service Act 1991) to provide the HQCC with a copy of the RCA report. Private health facilities can also give authority to the Chief Health Officer to on-forward copies of their RCA reports to the HQCC (pursuant to section 110 of the Hospital and Health Boards Act 2011).
RCA reports should include the following information:
- where the reportable event happened e.g. the name and address of the health facility or location details (for ambulance services)
- a description of the reportable event
- a statement of the factors the RCA team considers contributed to the happening of the event
- any recommendations about changes or improvements in a policy, procedure or practice relating to the provision of health services (or ambulance services), to reduce the likelihood of, or prevent, the same type of event happening again.
RCA reports should be sent to the HQCC as soon as practicable after the RCA commissioning authority has received the report from the RCA team.
When to send a reportable event summary review form
Healthcare providers are required (pursuant to section 21(1) of the Health Quality and Complaints Commission Act 2006
) to provide the HQCC with a completed reportable event summary review form
in the following circumstances:
- when an alternative form of review to RCA is conducted, and the review is completed on or after 1 July 2012; or
- when no review is conducted of a reportable event occurring on or after 1 July 2012; or
- when an RCA is commenced and then stopped, where the decision to stop the RCA is made on or after 1 July 2012.
Healthcare providers should send their reportable event summary review forms to us within 15 business days of:
- completing their review of the reportable event or
- their decision to not conduct a review of a reportable event or
- their decision to stop an RCA that has commenced.
Send RCA reports and reportable event summary review forms to the HQCC by:
The monitoring of all reportable events will strengthen our ability to meet our obligations under section 3(1)(a) of the Health Quality and Complaints Commission Act 2006
for the oversight and review of, and improvement in, the quality of health services and to carry out related functions. We will use reportable events information to monitor the quality of care provided by all health services in Queensland.