Part 8Analysis of adverse incidents

Part 8—Analysis of adverse incidents 68—Preliminary (1) In this Part, unless the contrary intention appears— adverse incident means an incident relating to the provision of health services by a health services entity or health services entities that falls within a class of incident specified by the Chief Executive by notice in the Gazette; authorised quality improvement body means a person or group of persons that is an authorised entity under section 64(1)(b); designated authority means— (a) the general manager or chief executive officer of a health services entity (however described); or (b) a person who is appointed by a health services entity to exercise the powers of a designated authority under this Part; or (c) an authorised quality improvement body; or (d) in relation to the investigation of an adverse incident involving a mental health patient or mental health services provided by a health services entity—the Chief Psychiatrist; health services entity means— (a) a hospital (including a private hospital); or (ab) an entity that provides health services at a private day procedure centre; or (b) an entity involved in the provision of a health service that is brought within the ambit of this definition by the regulations; RCA team means a team appointed under section 69. (2) This Part has effect despite the Freedom of Information Act 1991. (3) If the provisions of this Part are inconsistent with any other Act or law, this Part prevails to the extent of the inconsistency. 69—Appointment of teams (1) If an adverse incident involving a health services entity is reported to, or comes to the attention of, a designated authority, the designated authority may appoint a team (a root cause analysis or RCA team) to undertake an investigation and to provide reports in relation to the incident in accordance with this Part. (2) The RCA team may be constituted by such persons as the designated authority may determine after taking into account any requirements prescribed by the regulations. (3) The designated authority must ensure that a written record is kept of the persons appointed as members of the RCA team. (4) The purpose of an investigation is to identify issues within the system that contributed to or resulted in the occurrence of the adverse incident and to provide recommendations for measures to prevent a reoccurrence of a similar incident. (5) The procedures and processes adopted for the purposes of an investigation will be determined— (b) to the extent that the regulations do not regulate a particular matter—by the relevant team (taking into account any relevant protocols authorised by the health services entity or professional standards or requirements). 70—Restrictions on teams (1) An RCA team must not conduct an investigation into the competence of a person in providing health services. (2) If an RCA team has reason to suspect that its investigations may relate to an adverse incident that involves a prescribed act, the RCA team must suspend its activities and comply with the procedures prescribed by the regulations (and must not recommence its activities unless or until authorised under the provisions of the regulations). prescribed act means— (a) an act that is an offence under the law of the State that appears to have been committed by a member of the staff of the health services entity; or (b) an act that is attributable to a member of the staff of the health services entity, or any other person involved in the adverse incident, being medically unfit; or (c) an act that constitutes the abuse of a patient; or (d) an act that appears to be a deliberately unsafe act (other than an act that might be reasonably undertaken in the provision of a health service); or (e) an act brought within the ambit of this definition by the regulations. 71—Provision of information Information (including confidential information) may be disclosed to an RCA team without the breach of any law or principle of professional ethics. 72—Reports (1) An RCA team will, at the completion of its investigation of an adverse incident, prepare 2 reports— (a) one report that contains— (i) a description of the adverse incident, based on facts that, in the opinion of the RCA team, are known independently of its investigation; and (ii) the recommendations of the RCA team as to the need for changes or improvements in relation to a procedure or practice associated with the incident; and (b) a second report that contains 1 or more of the following elements, as the RCA team thinks fit: (i) a description of the adverse incident; (ii) a flow diagram; (iii) a cause and effect diagram; (iv) a causation statement; (v) the recommendations of the RCA team; (vi) the working documents associated with the RCA team's investigation and processes (incorporated as attachments); (vii) any other material considered relevant by the RCA team. (2) The report under subsection (1)(a) may be released publicly. (3) The report under subsection (1)(b) may only be released by the RCA team to— (a) a person who provides expert, technical, administrative or secretarial assistance to a member of the RCA team, or to the RCA team; (b) a person who is a member of an authorised quality improvement body; (c) in the case of that part of the report that constitutes the causation statement—a designated authority; (d) a prescribed person, or a person of a prescribed class, who is entitled to receive the report, or a prescribed part of the report, in accordance with the regulations. 73—Protection of information (1) This section applies to— (a) a person who is, or has been, a member of an RCA team; or (b) a person— (i) who provides, or has provided, expert, technical, administrative or secretarial assistance to a member of an RCA team, or to an RCA team, or in connection with the activities of an RCA team; or (ii) who acts, or has acted, for the purposes of receiving or gathering information on behalf of an RCA team; or (c) a person who receives a report under section 72(3). (2) A person to whom this section applies must not— (a) make a record of information gained as a result of, or in connection with, the activities of an RCA team; or (b) make use of or disclose information gained as a result of, or in connection with, the activities of an RCA team, except— (c) to the extent necessary for the proper performance of the activities of the RCA team (including as to the preparation of the reports required at the conclusion of the investigation); or (d) in pursuance of any reporting requirements of a prescribed kind; or (e) to the extent allowed by the regulations. (3) Without limiting subsection (2), a person to whom this section applies cannot be required— (a) to produce to a court, agency or other body any document that has been brought into existence for the purposes of the activities of an RCA team; or (b) to disclose to a court, agency or other body any information that has become known for the purposes of the activities of an RCA team. (4) Subsections (2) and (3) do not apply to— (a) information contained in the report of the RCA team that may be released publicly; and (b) any information or document that does not identify, either expressly or by implication, a particular person or particular persons. 74—Immunity provision No act or omission of a person in good faith for the purposes of the activities of an RCA team, or for the purposes of an activity that the person reasonably believes to be the activity of an RCA team, gives rise to any liability against the person, or against any governing body or other entity involved in authorising an RCA team to act under this Part. 75—Victimisation (1) A person commits an act of victimisation against another person (the victim) if he or she causes detriment to the victim on the ground, that the victim has provided, or intends to provide, information or other assistance to an RCA team in connection with an investigation under this Part. (2) An act of victimisation under this section may be dealt with— (a) as a tort; or (b) as if it were an act of victimisation under the Equal Opportunity Act 1984, but, if the victim commences proceedings in a court seeking a remedy in tort, he or she cannot subsequently lodge a complaint under the Equal Opportunity Act 1984, and conversely, if the victim lodges a complaint under that Act, he or she cannot subsequently commence proceedings in a court seeking a remedy in tort. (3) Where a complaint alleging an act of victimisation under this section has been lodged with the Commissioner for Equal Opportunity and the Commissioner is of the opinion that the subject matter of the complaint has already been adequately dealt with by a competent authority, the Commissioner may decline to act on the complaint or to proceed further with action on the complaint. (4) In this section— detriment includes— (a) injury, damage or loss; or (b) intimidation or harassment; or (c) discrimination, disadvantage or adverse treatment in relation to the victim's employment or business; or (d) threats of reprisal.