Clinical Risk Management Policy Template for Australian General Practices

What's in this template?

This clinical risk management policy is designed for Australian general practices preparing for RACGP accreditation under the Standards for General Practices (5th Edition). It maps directly to Criterion QI3.1 — Managing clinical risks and incorporates the ACSQHC Open Disclosure Framework.

The template covers 15 sections:

1. Purpose — systematic approach to identifying, assessing, managing, and monitoring clinical risks
2. Scope — all clinical risks, incidents, adverse events, and near-misses
3. Definitions — clinical risk, adverse event, near-miss, sentinel event, open disclosure
4. Risk Management Governance — Risk Management Officer, Practice Principal, all clinical staff responsibilities
5. Risk Identification — multiple sources (incident reports, complaints, audits, accreditation findings, safety alerts, external reviews)
6. Risk Assessment — likelihood × consequence matrix with 5-level scales, risk rating categories (low, medium, high, extreme)
7. Risk Treatment and Controls — hierarchy of controls (eliminate, substitute, engineer, administer, monitor)
8. Incident and Near-Miss Reporting — how, what, and when to report, no-blame culture statement
9. Incident Investigation — tiered investigation proportional to severity, root cause analysis for serious events, contributing factor identification
10. Open Disclosure — ACSQHC framework application, what to communicate, documentation, medical defence organisation advice
11. Clinical Risk Register — living document with risk descriptions, ratings, controls, actions, responsible persons, and status
12. Monitoring, Audit, and Review — quarterly incident review, risk register review at each meeting, annual clinical risk review
13. Education and Training — induction training, annual refresher, CPD encouragement, de-identified case studies
14. Related Policies — cross-references to Complaints, Handover, IPC, Privacy, WHS, Training
15. Review History — version control and approval

Editable placeholder fields

• {{practice_name}}, {{abn}}, {{practice_address}}, {{phone}}, {{email}}
• {{risk_officer_name}} — designated Risk Management Officer
• {{incident_form_location}} — where incident report forms are found
• {{practice_principal_name}}, {{review_date}}, {{next_review_date}}

RACGP accreditation requirement

Criterion QI3.1 requires that the practice has a system for managing clinical risks. Surveyors will typically check:

• A documented clinical risk management policy exists
• A clinical risk register is maintained and reviewed regularly
• Incident and near-miss reporting processes are in place and staff can describe them
• Reported incidents are investigated with documented corrective actions
• Open disclosure is practised when patients are harmed
• Clinical risk data is used for quality improvement

Key references

• RACGP Standards for General Practices (5th Edition) — Criterion QI3.1
• ACSQHC Open Disclosure Framework — the national standard for communicating with patients about adverse events
• ACSQHC National Safety and Quality Health Service Standards — while primarily for hospitals, the risk management principles apply to all healthcare settings

How to customise this template

1. Download and fill in all {{placeholder}} fields
2. Set up your clinical risk register — use a spreadsheet or your practice management system
3. Create your incident report form — a simple form capturing date, time, description, people involved, immediate actions, and contributing factors
4. Brief all clinical staff on the no-blame reporting culture and how to submit incident reports
5. Schedule your first risk assessment — walk through the practice with clinical staff to identify existing risks
6. Add clinical risk to your practice meeting agenda as a standing item

Frequently asked questions

What's the difference between clinical risk management and WHS?

Clinical risk management focuses on patient safety — risks that could result in harm to patients during their care. WHS (work health and safety) focuses on worker safety — risks to staff health and safety in the workplace. Some risks overlap (e.g. needlestick injuries), but the two systems serve different purposes and are assessed under different RACGP criteria.

What is open disclosure?

Open disclosure is an open, honest conversation with a patient when something goes wrong during their care. It involves explaining what happened, expressing regret, describing what is being done to investigate and prevent recurrence, and addressing the patient's ongoing clinical needs. It is not an admission of liability.

How do we create a no-blame culture?

A no-blame culture means staff can report incidents and near-misses without fear of punishment. Focus on system failures rather than individual blame. Investigate what went wrong in the process, not who to blame. When staff see that reporting leads to improvements (not discipline), reporting increases and patient safety improves.

Can I use this for AGPAL or QPA accreditation?

Yes. Both accrediting bodies assess against RACGP Criterion QI3.1. This template provides the documentation framework for risk management, incident reporting, investigation, and open disclosure that surveyors expect to see.