Paediatric resource toolkit - improving quality of SAC1 clinical incident reviews

Initiative Type
01 October 2019
Last updated
17 May 2020


The Queensland Paediatric Quality Council (QPQC) is developing a resource toolkit for use by patient safety officers and clinicians involved in paediatric clinical incident review. This toolkit will include a checklist of best practice, supporting resources, as well as presentations for education and training.

The toolkit/resources will be piloted and evaluated across two Hospital and Health Services (HHSs) (Gold Coast/Townsville or Bundaberg) as part of a Clinical Incident Roadshow that is being coordinated by the Queensland Children’s Critical Incident Panel (QCCIP) for patient safety officers and clinicians.

The QPQC will use these roadshows to present the toolkit and seek feedback on the effectiveness of the resources. Once finalised, the toolkit will be shared across HHSs and with the QCCIP and Patient Safety and Quality Improvement Service (PSQIS) to guide ongoing clinical incident review development and training.

Key dates
Jul 2019
Jul 2020
Implementation sites
All HHSs
Queensland Children’s Critical Incident Panel (QCCIP) and pilot HHSs


The goal of this project is to address concerns with the quality of some paediatric clinical incident reviews of the most serious of clinical incidents (those which have caused death or permanent harm). These quality concerns have been identified by QPQC's analysis of paediatric clinical incident review documents from all HHSs in Queensland.

Suboptimal quality of the incident reviews impacts on the identification of key learnings and recommendations for improving patient safety. The need for feedback on the quality of clinical incident reviews has been identified as a priority by both HHSs and the QCCIP.

This project will translate the learnings identified by the QPQC into tangible tools that can be used to improve clinical incident review quality and patient safety outcomes across the State.


High-quality incident reviews are more likely to identify opportunities for tangible local and system-wide improvement. Features of high-quality reviews include methodology factors such as optimal panel composition, consultation with patients/families, local service providers, external experts, and reference material, utilisation of quality tools, and development of recommendations that are classified as strong using the Department of Veteran Affairs “Hierarchy of Action Tool”.


All Queensland hospitals strive for a strong culture of quality and safety for children, however, adverse events are estimated to occur in up to 10 per cent of all hospital admissions. When adverse events occur, they are reviewed locally and recommendations for improvement are developed.

QPQC has identified issues with the quality of clinical incident analyses, which are impacting on the identification of factors that contribute to an adverse event and recommendations for improving patient safety.

Solutions Implemented

By utilising a Safety 2 lens, one outcome of the QPQC's thorough analysis of clinical incident reviews for incidents causing death or permanent harm SAC1 (Severity Assessment Category 1), has been the development of a tool kit of best practice features which characterise ideal methodology for clinical reviews. This toolkit is ready for presentation to and consultation with clinical and patient safety providers.

Evaluation and Results

Two pilot sites have been identified and the first workshop with QCCIP has been arranged. Based on feedback, the toolkit will be refined and taken to the second pilot site, again as part of the workshop with QCCIP. Feedback from that workshop and subsequent improvement will lead to the endorsement of the toolkit. It will then be shared with HHSs, QCCIP, PSQIS, and will be made generally available on the QPQC website.

Lessons Learnt

In developing the toolkit, the QPQC identified many best-practice innovative elements of clinical reviews, from individual patient safety teams around Queensland. After personal contact and feedback, these individuals were generous in sharing their innovations and have contributed to the current toolkit.

QPQC understands that HHS patient safety officers have much to contribute and have been inviting them in a visiting role to the QPQC incident analysis workshops.


Extensive Peer Reviewed literature.

Reports on RCA methodology from Queensland Health, Veterans Affairs, IHI.

Further Reading

Clinical Incident subcommittee. Multi-incident Analysis of SAC 1 Paediatric Clinical Incidents 2012-2014: Queensland State Summary Report. Queensland Paediatric Quality Council, July 2018.

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Key contact

Julie McEniery
Queensland Paediatric Quality Council
07 30681400

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