Management and Reporting of Undergraduate Nurse Incidents During Clinical Placement at RCH

Transcription

1 Management and Reporting of Undergraduate Nurse Incidents During Clinical Placement at RCH

2 Management and Reporting of Undergraduate Nurse Incidents During Clinical Placement at RCH Overview The purpose of this procedure is to provide a clear framework for Preceptors, the nursing Education Team and Nurse Unit Managers in the management and reporting of incidents in relation to undergraduate nursing students while on clinical placement at RCH. The policies and procedures related to risk management (see links below) that are currently in place at RCH still apply and should be followed. This Nursing Education procedure is to be used as an adjunct to the RCH policy, directly in relation to dealing with undergraduate nursing students in the event an incident occurs. The structure of this procedure is based on the Riskman consequence rating scale for ease of understanding and reporting an incident. For this procedure, the rating scale has been grouped into three groups to cover the broad areas of incident reporting and management. These are: Major or Catastrophic Incident Moderate Incident Insignificant or Minor Incident Each section also contains within it an escalation matrix to schematically represent the method by which each incident should be dealt with and subsequently reported. Related Policy Incident/ Injury/ Hazard reporting Risk management procedure for staff Definition of Terms Undergraduate nurse: an individual who is currently undertaking their final year in Bachelor of Nursing or Entry to Practice, Master of Nursing Science (University of Melbourne) degree at a relevant university and is taking part in a clinical placement at RCH as part of that course Incident: an accident or dangerous occurrence with potential to cause an injury Clinical placement: The course component of the Bachelor of Nursing taken outside the University within a health care facility where clinical education is undertaken through direct supervision by a Preceptor Education Team: Includes Clinical Nurse Educator (CNE) and Clinical Nurse Facilitator (CNF) group, Nursing Education (NE) team and the Undergraduate Nurse Educator. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 2 of 13

3 Procedure Details Major or Catastrophic Incident (incorporating Riskman consequence rating scale 4 & 5) Definition: Any event, or series of events, involving an undergraduate nurse that is sudden, overwhelming, threatening or protracted. Example: Any event that causes major or catastrophic harm to a patient, family member or other staff member either deliberate or non deliberate, direct or indirect. For example: incorrect administration of medication that is harmful incorrect procedure on patient causing injury assault (including aimed at undergraduate). Related Riskman Consequence Rating Scale Rating Dimension Major 4 Catastrophic 5 Patient Safety Access Major medical attention required Increased length of stay / readmission, requiring significant medical or surgical intervention. 7-9 DHS access targets not met. Unexpected / preventable death or permanent disability DHS access targets not met. Complaints Complaint requires escalation to Minister. Complaint requires escalation to Health SOS Board. Staff and Visitors Safety Significant irreversible disability to two persons. Single fatality or significant irreversible disability to > two persons. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 3 of 13

4 Reputation Prolonged adverse State media coverage Significant damage to the RCH name Ministerial enquiry. Prolonged adverse international or national media coverage Irreparable damage to the RCH name Complete loss of confidence of government and consumer Major inability to contract staff. Strategic Financial Non delivery of one key strategic objective Major delay in delivery of multiple strategic objectives. Financial loss of up to 1% of revenue. Complete non delivery of multiple key strategic objectives. Financial loss of greater than 1% of revenue. Compliance Environmental Major failure to comply with legislation and regulations ACHS Accreditation - Multiple high priority recommendations made. Environmental harm that is reversible within five years. Extreme failure to comply with legislation and regulations ACHS Accreditation withheld. Irreversible environmental harm and/or environmental harm that is reversible within 10 years. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 4 of 13

5 Escalation Matrix showing the chain of reporting for a Major or Catastrophic Incident Incident Ensure safety of all involved and deal with immediate consequences See also Incident/Injury/Hazard reporting procedure After hours: (Only) Contact after hours coordinator on page 4000 Preceptor/CNE/F or after hours coordinator - contact Director Nursing Workforce Development directly ext If unable to contact try admin supervisor on ext Time frame: same day. Report incident to NUM Risk man lodged by Preceptor (or anyone else applicable) NUM sends report to Nursing Education Quality sends report to NUM Director Nursing Workforce Development informs Undergraduate Nurse Educator Director Nursing Workforce Development contacts appropriate University to inform of incident Report to RCH Executive Director of Nursing Undergraduate Nurse Educator works with ward and applicable others to risk manage event and prevent re-occurrence Nursing Education provides feedback to involved parties to inform of outcome Undergraduate Nurse Educator sends report of risk man to University Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 5 of 13

6 Moderate Incident (Riskman rating scale 3) Definition: Any event or series of events involving an undergraduate nurse that causes unexpected and reversible harm to a patient, family member or staff or causes harm to the hospitals credibility / confidentiality. Example: Incorrect administration of medication that is non harmful or potentially but not actually harmful Posting details of RCH information on line Contamination with biological material. Riskman Consequence Rating Scale Rating Dimension Moderate 3 Patient Safety Moderate medical attention required Increased length of stay / re-admission or additional operational procedure. Access 4-6 DHS access targets not met. Complaints Complaint requires escalation to CEO / Executive. Staff and Visitors Safety Significant reversible disability to < two persons Major stress. Reputation Adverse State or local media coverage Moderate damage to the RCH name Some staff choosing to go to other hospitals. Strategic Major delay in delivery of a key strategic objective. Financial Financial loss of between $50,000-$500,000. Compliance Serious failure to comply with legislation and regulations ACHS Accreditation - A high priority recommendation made. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 6 of 13

7 Environmental Environmental harm that is reversible within two years. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 7 of 13

8 Escalation Matrix showing the chain of reporting for a Moderate Incident Incident Ensure safety of all involved and deal with immediate consequences See also Incident/Injury/Hazard reporting policy Preceptor/CNE/F contact Undergraduate Nurse Educator. If unable to contact try admin supervisor on ext Time frame: within same week Report incident to NUM Riskman lodged by undergrad or Preceptor (or anyone else applicable) Undergraduate Nurse Educator informs Director Nursing Workforce Development Report to EDON at discretion of Director NWD NUM sends report to Nursing Education Quality sends report to NUM Undergraduate Nurse Educator to contact appropriate University to report Undergraduate Nurse Educator provides feedback to involved parties to inform of outcome Nursing Education works with ward and applicable others to risk manage event and prevent re-occurrence Nursing Education sends report of risk man to University Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 8 of 13

9 Insignificant or Minor Incident (Riskman rating scale 1&2) Definition: A near miss that does not cause harm to patient, family member or staff but had the potential to if the action had been carried out. Alternatively, very minor harm causing a minor impact on increased length of stay, client satisfaction or clinical outcome. Example: Incorrect procedure almost performed on patient but caught in time. Riskman Consequence Rating Scale Rating Dimension Insignificant 1 Minor 2 Patient Safety Access Error / incident that had the potential to cause a consequence but on this occasion did not (near miss) Negligible impact on quality of care. 1 DHS access targets not met. First aid required Patient requiring increased the level of care. 2-3 DHS access targets not met. Complaints Minor complaint dealt with routinely through a telephone call. Complaint requires action to be taken by Compliance Manager. Staff and Visitors Safety First aid treatment only. Minor medical attention required Poor staff morale. Reputation Displeasure of staff voiced internally only. Low level damage to the RCH name. Strategic Negligible impact on delivery of a strategic objective. Minor delay in delivery of a key strategic objective. Financial Financial loss of below $10,000. Financial loss of between $10,000 - $50,000. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 9 of 13

10 Compliance Insignificant legal issues, noncompliances and/or breaches ACHS Accreditation - A recommendation made. Minor legal issues, non-compliances and/or breaches ACHS Accreditation - Multiple recommendations made. Environmental Single incident resulting in no material environmental harm. Minor, transient environmental harm. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 10 of 13

11 Escalation Matrix showing the chain of reporting for an Insignificant or Minor Incident Minor or insignificant Incident Preceptor reports to AUM +/or CNE/F & Undergraduate Nurse Educator (depending on incident and time it took place) Time frame: before the end of placement CNE/F &/or Undergraduate Nurse Educator ensures learning opportunity and debriefing has taken place Submit Riskman if deemed appropriate (keep in mind that Riskman should also be used for near miss events) Applicable NUM sends report to Nursing Education Quality sends Riskman report to NUM Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 11 of 13

12 Individual responsibility in reporting of an incident involving an undergraduate nurse: Undergraduate nurse Report incident immediately to your Preceptor, AUM (or Undergraduate Nurse Educator) Seek first aid/medical treatment for self or patient immediately. Preceptor / AUM / CNE/F Adhere to Incident/ Injury/ Hazard reporting procedure ( Report incident to NUM Submit a Riskman report. Ensure the undergraduate nurse is involved in this process as a learning experience (if appropriate to circumstances) Contact the Director - Nursing on ext to inform of major or catastrophic incidents only. Contact the Undergraduate Nurse Educator for any other incidents. NUM Adhere to Incident/ Injury/ Hazard reporting procedure ( Forward the Riskman report to Director - Nursing Education once received from Quality. Undergraduate Nurse Educator Work with appropriate personal to manage the incident (in conjunction with Director Nursing Education for major or catastrophic incidents) Provide feedback to ward and undergraduate nurse of the outcome of the incident and changes that will be/have been made to prevent re-occurrence Contact the University to inform of a moderate incident and a minor incident if appropriate. Director Nursing Workforce Development Contact the appropriate University to inform them of any major or catastrophic incidents Report any major or catastrophic incidents to Executive Director of Nursing. After Hours Coordinator Contacted only for major or catastrophic incident Remind the staff to submit a Riskman report Contact by phone (only if appropriate to circumstances) or the Director - Nursing Education the first opportunity to inform of incident. Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 12 of 13

13 Reference This procedure has been written based on recommendations made in the KPMG audit: The Royal Children s Hospital, Internal audit report of Undergraduate Nurse Placement Program September, Royal Children s Hospital Policies: Incident/ Injury/ Hazard reporting Risk management procedure for staff. Contacts For comment and changes to this policy, please contact the Nursing Education Nurse Educator, Undergraduate Nurses: Laura Turnbull Director- Nursing Education: Melody Trueman Ext Author: P. Stephenson, modified by L. Turnbull, December 2012 Management and Reporting of U/G Nurse Incidents during Clinical Placement at RCH Page 13 of 13