New v1.0 Date: November 2015 Sarah Hankey - Risk & Claims Manager. Liz Lockett - Associate Director of Quality & Risk

Transcription

1 Corporate Incident Reporting: Standard Operating Procedure Document Control Summary Status: Version: Author/Title: Owner/Title: Approved by: Ratified: Related Trust Strategy and/or Strategic Aims Implementation Date: Review Date: Key Words: Associated Policy or Standard Operating Procedures New v1.0 Date: November 2015 Sarah Hankey - Risk & Claims Manager Liz Lockett - Associate Director of Quality & Risk Policy and Procedures Committee Date: 17/12/2015 Policy and Procedures Committee Date: 17/12/2015 Risk Management Strategy December 2015 December 2018 Near Miss Adverse Event Incident Policy Contents 1. Introduction Purpose Scope Process for Reporting an Incident or Near Miss Process for Monitoring Compliance and Effectiveness References... 5 Appendix 1... Adverse Incident Response Flowchart Appendix 2... Incident Form (If not on Safeguard) Page 1 of 7

2 Change Control Amendment History Version Dates Amendments 1. Introduction 2. Purpose Incident management underpins a basic part of the risk management framework for South Staffordshire and Shropshire NHS Foundation Trust. It is important that incidents are reported and investigated in a consistent way and that lessons learnt are shared within the organisation to reduce the likelihood of similar incidents occurring within our services. This policy supports the Incident Policy. This Standard Operating Procedure should be read in conjunction with the Incident Policy This Standard Operating Procedure has been developed to ensure robust processes in respect to the identification, reporting, responding to and learning from all incidents. 3. Scope This Standard Operating Procedure applies to all health and social care staff working within South Staffordshire and Shropshire NHS Foundation Trust, including those employed on a bank, agency or locum basis. 4. Process for Reporting an Incident or Near Miss All staff must ensure that any incident or near-miss event, involving themselves or any other individuals and/or property is immediately reported on the Safeguard system 1. Where there is no access to Safeguard an Adverse event form must be completed and sent to the manager, Clinical Lead and Risk Management. 1 Further information on incident reporting using Safeguard can be found in the Staff Handbook located on the Safeguard system Page 2 of 7

3 If immediate actions are required the person reporting the incident should ensure these actions are carried out or notified to a responsible person who has authority to carry out the action required. As soon as this manager/ identified person is made aware of this incident or nearmiss they must:- Conduct an immediate assessment of the situation to determine the nature and severity of the impact of the incident or near-miss upon clinical care and/or service delivery. Ensure that any individual who may have sustained an injury resulting from the incident receives immediate first aid and/or medical treatment. Take any immediate action necessary to make the area safe and reduce the risks of a reoccurrence. Determine whether the incident/near-miss should be considered to be a serious incident (See Incident policy). Once a decision has been made the process for reporting either an incident or serious incident should be followed. Determine whether the incident requires further investigation for example; If the incident has formed part of a cluster of incidents either similar in nature, individual or by locality If the actual harm is significantly lower than the potential harm It is a medicines administration error. Once it has been determined that the incident is not a serious incident or Duty of Candour the following actions will be taken:- The manager must assess whether a local review is required if a trend or cluster of incidents is becoming apparent. Where actions are taken these must be recorded on the incident form for future reference. In the event that any actions or recommendations cannot be implemented immediately then they must be entered onto the risk register for the relevant Directorate. The actions identified through this process will be monitored for implementation and escalated where required through the risk register review process. All Service Managers/ Heads of Service must ensure that any identified lessons learnt as a result of a local incident are reviewed at monthly team meetings Attention is drawn to the fact that there may be times when it is identified that there is a worrying pattern of less serious incidents or events that need further examination to understand fully. Often such patterns or trends are identified through routine incident data analysis undertaken within the Risk Management Department. When this occurs local discussion will be held between the Risk Management Department and the Associate Director for Quality and Risk and relevant Service Manager to determine whether or not it would be prudent to undertake a further review of this matter. Page 3 of 7

4 5. Process for Monitoring Compliance and Effectiveness Monitoring of the implementation of this policy will be through monitoring of and responding to exception reports including Serious Incidents, incidents and near misses. 6. References 1. NHS Commissioning Board Serious Incident Framework March sirl/ 2. Department of Health, December Safety first: a report for patients, clinicians and healthcare managers. 3. Department of Health, April Building a safer NHS for patients - implementing an organisation with a memory ce/dh_ Department of Health, June 2000 An organisation with a memory: Report of an expert group on learning from adverse events in the NHS ce/dh_ The National Patient Safety Agency. (2003). Seven Steps to Patient Safety Department of Health(2005) Independent investigation of adverse events in mental health services asset/dh_ pdf Page 4 of 7

5 Adverse Incident Response Flowchart Annex 1 Incident Occurs Staff member involved in/observing incident to immediately inform ward/team manager (delegated person in charge) so that the incident can be risk rated. NO Is there access to Safeguard? YES Staff member involved in / observing incident to immediately complete incident report on AER Incident form to be risk rated agreed & signed off by ward / team manager (delegated person in charge) within 24 hours of incident occurring Staff member involved in / observing incident to immediately complete incident report on Safeguard Ward / Team Manager (delegated person in charge) reviews the incident on Manage incidents within 3 working days Ward / Team Manager (delegated person in charge) grades incident: Incident form to be forwarded to Service Manager, Clinical Lead and Risk Management within 48 hours of incident occurring Incident risk rating reviewed by Risk Management and entered onto Safeguard Severity score of 4 or 5 Implement Serious Incident process Severity score of 3 (Patient Safety Incident) Implement Duty of Candour process Area of Concern identified Carry out investigation on the day of on incident / next Ward / Team Manager (delegated person in charge) working provides feedback day to reporter and actions any identified improvements Incident Dashboard reviewed at monthly Team meetings to identify and response to any patterns/trends/clusters Page 5 of 7

6 Incident Form (if not on Safeguard) (For All Adverse Events and/or Near Misses) Annex 2 1. Incident Details (When and Where) 1.1 Date of Incident? (Please Type Date Here) 1.2 Time of Incident? (Please Type Time Here) 1.3 Directorate? (Please Type Details Here) 1.4 Site? (Please Type Details Here) 1.5 Team? (Please Type Details Here) 2. Subject/Affected Person of Incident (Person, Team etc. Injured/Harmed or at Risk) 2.1 Status? Please Select (Click Here) 2.2 If Staff or Contractor - What is the Job Title? (Please Type Details Here) 2.3 Workbase/Team? (Please Type Details Here) 2.4 Patient NHS Number? (Please Type Details Here) 2.5 Surname? (Please Type Details Here) 2.6 Forename(s)? (Please Type Details Here) 2.7 Male/Female? Please Select (Click Here) 2.8 Address and Contact Number? (Please Type Details Here) 3. Instigator of Incident (If Applicable Person Causing the Risk or Concern) 3.1 Status? Please Select (Click Here) 3.2 If Staff or Contractor - What is the Job Title? (Please Type Details Here) 3.3 Workbase/Team? (Please Type Details Here) 3.4 Patient NHS Number? (Please Type Details Here) 3.5 Surname? (Please Type Details Here) 3.6 Forename(s)? (Please Type Details Here) 3.7 Male/Female? Please Select (Click Here) 3.8 Address and Contact Number? (Please Type Details Here) 4. Incident Description (Please Describe What Happened and Record Fact Only) 4.1 Details of Incident: (Please Type Details Here) 5. Consequences/Injury Details (Who Was Injured and What Injuries Were Sustained)? 5.1 Injury Details: (Please Type Details Here) 6. Police Involvement 6.1 Was the Incident Reported to the Police? Please Select (Click Here) If No, Please Proceed to Section What Date Was it Reported? (Please Type Date Here) 6.3 Time Reported? (Please Type Time Here) 6.4 Station? (Please Type Details Here) 6.5 Incident/Crime Reference Number? (Please Type Details Here) Page 6 of 7

7 6.6 Did the Police Attend the Incident? Please Select (Click Here) If No, Please Proceed to Section Date Attended? (Please Type Date Here) 6.8 Time Attended? (Please Type Time Here) 6.9 From Which Station? (Please Type Details Here) 6.10 Name and Number of Attending Officer(s)? (Please Type Details Here) 7. Assessment of Severity of Incident and the Likelihood of Recurrence Consider all the information obtained on this form and make an assessment based on the scoring system (1-5) and select the figures below (see policy for more information). 7.1 Severity of Incident: Please Select (Click Here) 7.2 Likelihood of Recurrence: Please Select (Click Here) 8. Action Taken (What, When, By Whom and Other Actions e.g. HSE (RIDDOR), Police) 8.1 Action Taken: (Please Type Details Here) 9. Action Recommended (What, When and By Whom) 9.1 Action Recommended: (Please Type Details Here) 10. Comments of Subject, Instigator or Affected Person 10.1 Comments Made: (Please Type Details Here) 11. Witnesses (Names and Addresses or Witnesses Where Applicable) 11.1 Witnesses: (Please Type Details Here) 12. Person Completing the Form (Complete Unless Reporting Anonymously) 12.1 Name? (Please Type Details Here) 12.2 Job Title? (Please Type Details Here) 12.3 Workbase/Team?: (Please Type Details Here) 12.4 Date Incident Form Completed? (Please Type Date Here) 12.5 Contact Number? (Please Type Details Here) Thank you for completing this incident form. Could you please continue to send this form to the following, secure address: risk.management2@nhs.net Page 7 of 7