ADVERSE INCIDENT REPORT FORM (AI-1)

Transcription

1 REF NO: ADVERSE INCIDENT REPORT FORM (AI-1) This form should be used to report any incident/accident or potential incident (i.e. a near miss ) which has caused loss, harm or damage, or has the potential to cause loss, harm or damage to any individuals involved, or loss or damage in respect of property/equipment for which the Trust is responsible. This includes any incident that has the potential to involve the Trust in either litigation or adverse publicity. IN THE EVENT OF A SERIOUS INJURY OR DEATH, THE INCIDENT SHOULD BE REPORTED IMMEDIATELY TO LINE MANAGERS AND THE RISK MANAGEMENT TEAM OR, IF OUT OF OFFICE HOURS, TO THE ON CALL MANAGER. Guidance notes are available for reference when completing this form, and if doubt exists in relation to certain sectors, then these notes should be consulted. Please contact the Risk Department for further advice if required. Once this form is completed, please ensure that is it passed to your line manager for update and further completion. The form should then be sent to the Risk Management Team at Trust HQ, Willerby Hill, Willerby, HU10 6ED. Only facts (not opinions) which are relevant to the incident should be reported. REPORTS MUST BE COMPLETED WITHIN 10 WORKING DAYS Workplace Care Area of Person or Property Affected/Harmed/Damaged: Exact Location (room, patient s home etc): Date of Incident: Time of Incident: Date Incident Reported: Type of Person Affected/Harmed:- SECTION 1 Location and Identification Staff Patient Visitor Contractor Volunteer Other If Other, please state: Details of Person Affected:- DOB: Male: Female: Ethnicity: Religion: Sexual Orientation: Job Title if Staff Member: Inpatient or Out/Day Patient if Patient: NHS No: Is Patient detained under the MHA 1983? (please circle): No Yes Section: CPA: No Yes Contact Details (Tel/ ): Manager s Name: 1

2 Brief Description of Incident: (If property is involved, who is it owned by? If incident involves an inpatient was he/she restrained or secluded? If Police were involved, please record log number.) SECTION 4 - Injury SECTION 3 Category of Incident SECTION 2 Description of Incident * If there are any witnesses to the incident, please complete and attach a witness statement form(s) * Medication Related Incident Yes No (If Yes please complete the Medication Incident Form (PMI 01) available on the Medication Management Intranet site) If the Incident is one of Violence & Aggression, please state (if applicable):- (If the person assaulted is an NHS Employee also complete a PARS form please.) Name of Assailant: NHS No: DOB: Section: CPA: No Yes If Incident is a Missing Patient/Client, please state:- Date Missing: Date Returned: Time Missing: Time Returned: If Returned, Please State How (Police, Own Volition, Staff etc.) Is this Incident RIDDOR Reportable? (If Yes please complete a RIDDOR Form) No Yes Also, if Yes please state Why (i.e. a major injury, a more than 3 day injury etc): Part of Body Injured (please indicate side where appropriate, i.e. left or right): Nature of Injury (i.e. cut, abrasion, bruise, strain, sprain, fracture, burn, fatality etc): Treatment received (i.e. first aid, A&E, GP/Doctor, admission to acute hospital etc): 2

3 Safeguarding Adults / Children Has a Safeguarding Alerter been Completed? Yes No SECTION 5 Safeguarding Issues If Yes is the Safeguarding Issue relating to an: Adult Child (please attach a copy of the Alerter to the Adverse Incident Form) If No and Adult please state Why an Alerter was Not Completed: (a). The Police were Informed (b). The Patient has Capacity and did not want it reporting (c). Staff did not class it as a Safeguarding Issue (d). Other (please state) SECTION 6 Further Notification Police: Relative: Senior Manager: HSE: Date: Date: Date: Date: If Senior Manager: Name: Job Title: Please Note: A Copy of the adverse incident report should be forwarded to your Line Manager to enable an investigation to be carried out and the adverse incident investigation form to be completed and returned to the Risk Management Team. Person Completing This Form Job Title: Signature: Date: Type of Incident FOR OFFICIAL USE ONLY (TO BE COMPLETED BY THE RISK MANAGEMENT TEAM ONLY) Type of Incident: 3

4 ADVERSE INCIDENT INVESTIGATION FORM To be completed by Line Manager and forwarded to the Risk Management Information Team within 10 working days Date Incident Occurred: Date Form Received by Line Manager: Risk Rating of Incident Assessment: SECTION 8 Risk Assessment SECTION 7 Risk Rating Date Completed: Completed by: Consequence (please circle) Insignificant Minor Moderate Major Catastrophic Likelihood (please circle) Rare Unlikely Possible Likely Almost Certain Please Circle: Was a Risk Assessment Undertaken Prior to this Incident? NO YES Was a Clinical Risk Assessment Undertaken? NO YES Have Identified Controls been Implemented? NO YES Has a Risk Assessment been Reviewed as a result of this Incident? NO YES Have Revised Control Measures been Implemented? NO YES SECTION 9 Root Causes & Contributory Factors Please consider the following Factors: Communication e.g. lack of information within or between teams Education & Training e.g. availability, appropriateness, lack of training at induction, mandatory, professional Equipment & Resources e.g. lack of equipment, suitability, inadequate maintenance Medication e.g. prescribing and administration issues 4

5 Organisation & Strategic e.g. culture, goals, priorities SECTION 9 Root Causes & Contributory Factors continued Patient e.g. diagnosis, condition Task e.g. lack of policies, guidelines, decision making aids Team & Social e.g. lack of team roles, leadership, support, culture Work & Environment e.g. staffing levels Any Other e.g. inter-agency working Action Plan: Action Time Scale Lead Person Date Completed Review Date SECTION 10 Action Plan Line Manager/Deputy Completing This Form: Contact Details (telephone & ): Signature: Date: 5