National safety priorities in mental health: a national plan for reducing harm

Risk identification and management

Page last updated: October 2005

Incident reporting and management play a vital role in an organisation's approach to collecting, analysing and learning from information about when things go wrong in health care. There are a variety of ways of identifying risks and the likely outcomes of adverse events, however, there is no nationally agreed approach for the use of this information in the health or mental health sector.

Risk matrices are commonly used tools. The Australian Council for Safety and Quality in Health Care, in its Open Disclosure Standard, provides the example of an incident grading matrix from AS/NZS 4360 Risk management - a standard that is relevant beyond the health sector. Similarly, the Safety Assessment Code (SAC) promoted by the US Department of Veterans Affairs' National Centre for Patient Safety and the Severity Assessment Code (SAC) are widely used. These matrices (see Appendix 7 for examples) provide a system for mapping the likely or expected frequency of an adverse outcome by the severity of the outcome/impact.

Mental health services are encouraged to use such tools when prioritising actions to prevent adverse outcomes or when determining appropriate responses to incidents. Risk management or incident classification tools can assist to determine what outcomes and incidents automatically prompt further inquiry or response, can assist in managing the response, and raise awareness of incidents and incident reporting requirements.

These risk matrices, and other documents and tools developed by the Australian Council for Safety and Quality in Health Care (see Appendix 2) are appropriate for use, or could be adapted for use, in mental health services.

Risk management and incident management relies on strong governance arrangements, a culture of quality improvement and associated processes, as well as support from information systems that provide good quality reliable data about adverse events for quality improvement.