Department of Health

Investigation of clinical incidents

The investigation of a clinical incident is an important component of an effective incident management system. All incidents notified in the Victorian Health Incident Management System (VHIMS) are allocated an incident severity rating and require an investigation or review process.

The three methodologies available to health services for investigating clinical incidents are:

  • root cause analysis
  • in-depth case review
  • local investigation and aggregate review.

Clinical incident investigations and responsibilities

Victorian health services must investigate all clinical incidents, and clearly communicate the roles and responsibilities of all staff.

Clinical incident investigations - root cause analysis

Root cause analysis is a detailed and thorough investigation performed for sentinel events or critical incidents that have a severity rating of 1.

Root cause analysis (RCA) statements and reports

Root cause analysis statements and reports show the cause-and-effect relationships of an incident, and make recommendations to reduce the risk of recurrence.

Clinical incident investigations - in-depth case review

In-depth case reviews determine the intrinsic aspects of a system failure and identify opportunities for process improvement.

Reviewed 11 November 2021

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Contact details

Postal address: GPO Box 4541, Melbourne VIC 3001

Quality and Safety Branch Department of Health

Phone +61 3 9096 7258
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