Healthcare Identifiers Act and Service Review - Final Report - June 2013

5.1 Clinical safety processes

Page last updated: 28 November 2013

There is ongoing work between NEHTA and DHS to improve the issue identification, management and resolution processes for the HI Service. Increasingly though, issue investigation cannot be restricted to the boundaries of the HI Service and requires collaboration between the HI Service and the PCEHR system (and ultimately other e-Health programs) to identify where the interaction between the Healthcare Identifiers and other systems may have contributed to the issue. It is anticipated that impacts of issues may increase now the Service is being used more widely as a component of e-Health services. The implementation schedules of other initiatives mean that there will be a spike of implementations in the next 12 months and the ability to resolve issues and act quickly on change requests will be critical.

Open collaboration between organisations to identify and resolve incidents are critical to ensure that issues are resolved quickly and do not pose a clinical safety risk. There needs to be a formalised feedback loop implemented when an incident occurs. It was reported that there is no formal feedback loop on how an issue has been resolved if issues are raised by a user because of constraints on disclosure. It is important that correct details are provided back to sites that lodge an issue to maintain data quality and reduce clinical risk.

It is inevitable that there will be issues that will occur with the HI Service. In order to continuously improve the quality of the Service and to maintain a high level of confidence there needs to be a culture of disclosure when an incident does occur and transparency in processes and in the resolution that is put in place.

Incorporating ongoing prospective surveillance to identify potential mismatches will be important, not just within DHS but in the clinical systems in healthcare organisations. There is always a risk that misidentification will occur because of the human steps in the process.

Recommendation 20 – Clinical Safety

It is recommended that potential clinical safety incidents occurring in any national e-Health system be reported through a single point of entry and that a single entity is allocated responsibility for co-ordinating the resolution of these with the appropriate managing agency.

Recommendation 21 – Issue resolution

It is recommended that the governance structure for incident investigation for the PCEHR system be reviewed to ensure the effective co-ordination of actions between the HI Service Operator and the PCEHR System Operator to resolve incidents related to the HI Service that impact the PCEHR system and downstream systems.

Recommendation 22 - Issue management

It is recommended that a process of structured analysis of adverse events that are related to misidentification be implemented to identify process issues that could be addressed through system or business process change.

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