Introduction This procedure forms part of NWAS Health & Safety Policy with regard to the reporting and monitoring of incidents. Guidance for the completion of NWAS Incident report form All incidents and near misses must be reported by filling out the NWAS incident report form (IRF) A.S.A.P. All incidents must be investigated and actions taken to prevent recurrence where appropriate, the depth of the investigation will depend on the severity and complexity of the incident. The IRF can be completed using paper format or via electronic format which can be found on the intranet and at your work place. When the form has been completed a copy must be forwarded to your line manager, within 24hrs, who will forward to the Area HealthCare Governance department. Information taken from the forms is entered on the Datix risk management database. Frequently Asked Questions What is an Incident? An incident is any untoward event that potentially or actually places an individual, group, buildings, equipment or the organisation as a whole at risk. Incidents can include but are not limited to human error or misconduct, equipment or systems failure, and deliberate actions on the part of patients or staff. Incidents can occur in all areas of our work and are not limited to clinical care. A clinical incident is defined as an unexpected event occurring during treatment, or an unexpected result of treatment which may, or does, cause harm to the patient. Non-clinical incidents are any other events affecting staff, clients or other visitors to Trust premises. A near miss is an event that might have become an incident if action had not been taken in time to prevent this. What incidents do I need to report? All incidents that are Clinical and Non clinical related, including hazards and near miss must be reported. That involves staff, patients, building, security, vehicle, equipment and anything that is necessary that has an effect on the risk of the Trust. If it s not reported it s not an incident. This includes the flagging of address without an IRF the address cannot be flagged or investigated further. NWAS: Incident report form IRF Page: 1 Of 8
I have had an incident what do I fill out? All incidents and near misses must be reported by filling out the NWAS incident report form (IRF) A.S.A.P. All incidents must be investigated and actions taken to prevent recurrence where appropriate, the depth of the investigation will depend on the severity and complexity of the incident. (See Incident Reporting and Investigation Policy for more details). Who is responsible for reporting incidents? Immediately after an incident, it is the responsibility of the person involved at the time to ensure that an incident form is completed. It is the responsibility of all members of the Trust staff to bring any incident or near misses to the attention of their line manager so that appropriate action can be taken When do I complete an Incident report form? All incident report forms must be filled as soon as possible especially where injuries or occupational illnesses are involved or where there has been a near misses to either an employee, patient or member of the public. These must be passed to your line manager within 24hrs of the incident happening. Your line manager must then investigate the incident fully and forward the IRF to the HealthCare Governance department with 72hrs of the incident happening. How do I know what is a non-clinical and clinical incident? Non-clinical incidents are any other events affecting staff, patients or other visitors to Trust premises. A near miss is an event that might have become an incident causing damage to persons or property if action had not been taken in time to prevent this. Clinical incidents are defined as an unexpected event occurring during treatment, or an unexpected result of treatment which may, or does, cause harm to the patient. See further definition below under definitions. Where can I find an Incident report form? A blank copy of the IRF is available at all stations, area offices and from your line manager. If you are still having difficulties locating one that speak to any of the Healthcare Governance team NWAS: Incident report form IRF Page: 2 Of 8
Why do I fill out an IRF? Why is reporting important? Incident reports enable NWAS to identify where things have gone wrong so that the Trust can ensure that they do not happen again. Incident reporting is extremely important in helping the Trust to understand where risk lies, themes and any trends that are occurring. Reporting also helps with any potential claims that arise from an incident. Open and honest incident reporting is encouraged by the Trust and this means that you will not be held accountable for an incident simply by reporting unless by doing so you act in a manner which is malicious, negligent or breaches your code of professional conduct. Reporting incidents promotes learning within the organisation. When an incident occurs it is easy to feel you are the only person that this has happened to, yet it is rare that something happens because of the actions of one person. Sharing the experience enables us to look at the systems in which you work and the contributory factors which may have increased the likelihood of that event occurring. Isolated incidents may seem trivial or of little consequence. However, the aggregated data may show certain trends which are impacting on your ability as a member of staff to provide the level of care you would like to for your patients. The sign of a good reporting system is one where the number of incidents reported increases, but their severity falls. This is an indicator that staff are identifying risks earlier, before they become more serious and feel able to report incidents without the fear of being criticized by other staff. This helps to build an open and fair culture. How do I fill it in? Fill out the appropriate section of the forms, where sections are not relevant clearly strike through with N/A. For all incidents the following must be completed: Date of incident Time of incident in 24hr clock Type of incident Location Name and address of injured person in the relevant section Employee or other type of person Details of injury About the incident Any witnesses Who was informed? Signature NWAS: Incident report form IRF Page: 3 Of 8
What happen next after completion? After you have completed all the relevant sections as necessary, pass this to your line manager who will carry out an investigation into the incident as necessary. Once completed and sent to the Healthcare Governance department these are screened to ensure they are completed. These are then inputted to the Datix risk management software and given a unique reference number. We have 10 days to verify if an incident falls within the scope of RIDDOR Regulations 1995 and report the details to the HSE, this will be carried out the Healthcare Governance team. What do if I don t understand some of the sections? You can seek guidance from your line manager or speak to any one of the Healthcare Governance staff. Should I keep a copy? Keeping a copy is entirely up to you, but you are encouraged to keep one, or request a copy of one from your line manager or Healthcare Governance. What if I can t fill out the form? In the event that you are unable to fill out the form speak firstly with your line manager who will assist in the completion of the form. If you are unable to complete an IRF, your colleague may complete the form on your behalf but it is important to tell your line manager first. Note though that the form must be completed within 24hrs of the incident happening under normal situations. What do I do with the completed incident report form? After completing all the sections relevant to the incident, pass the incident report form to your line manager who will fill out the other relevant sections with regard to the investigation of the incident. NWAS: Incident report form IRF Page: 4 Of 8
How are incidents graded? Incidents are graded using the risk management guide; the consequence is multiplied by the likelihood which grades the incident. Likelihood Consequence 1 2 3 4 5 1 1 2 3 4 5 2 2 4 6 8 10 3 3 6 9 12 15 4 4 8 12 16 20 5 5 10 15 20 25 A copy and further detail of this can be found in the Risk Management Policy and Incident Reporting and Investigation Policy. Where can I get help and support after an incident occurred? There are a range of options for support and help after an incident. These are laid out in the incident report and investigation policy. However you are strongly advised to discuss and support needs with your line manager, and they should help you explore the options and access the type of support that you need. Definitions for IRF Access/ administration/ transfer issue Situation or event where clinical care has been delayed or affected. Clinical Assessment A procedure where the minimum that should be performed for every patient contact is a primary survey Clinical Incident An event or omission arising during clinical care and causing physical or psychological injury to a Patient (DOH An Organisation With Memory 2000) Clinical treatment The management of the patients condition following clinical assessment Consent/communication/confidentiality An event/incident where a patient has not given their permission to a healthcare professional before they examine or treat them. Where the legal and ethical obligations that prevent disclosure of patient information to third parties have been contravened NWAS: Incident report form IRF Page: 5 Of 8
Controlled Drugs (i.e. Morphine) Damage/loss/fault of Asset Documentation Equipment fault Fire Infection Control Manual Handling Medication issue Near Miss Patient Injury Physical assault RTC/Vehicle Sharps/Needlestick An event or incident with morphine a dangerous or otherwise harmful substance that belongs to a group of medicines that have the potential for abuse Home office Legislation Misuse of Drugs Act 1971 Equipment / medical device / vehicle / station failure or loss that may be irreplaceable All paperwork including clinical records Medical device and equipment that has a fault which can be fixed Fire is a chemical reaction called combustion, resulting in the release of heat, light and smoke Body Fluids: blood, Blood is the most high-risk urine, sputum, fluid, but the same wounds, splashes etc precautions should be followed when handling other body fluids. An operation in which the transportation or support of a load is undertaken by the use of physical force applied either directly or indirectly to the load. Such operations include lifting, lowering, pushing, pulling carrying, throwing or catching. A situation in which an event or omission occurs where a substance administered by mouth, applied to the body or introduced into the body for the purpose of treatment A situation in which an event or omission, or a sequence of events or omissions, arising during clinical care fails to develop further, whether or not as the result of compensating action, thus preventing injury to a patient ( An Organisation with a Memory DOH September 2000). Any incident where by a patient receives an injury whilst in the care of the Ambulance Service. intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort An incident involving a vehicle causing injury to Patients, members of the public or member staff, or damage to any property. An incident that causes a penetration injury resulting from the following :- Needles Drug ampoules/vials Razor blades Giving sets Lancets Scissors Cannulas Scalpels/blades NWAS: Incident report form IRF Page: 6 Of 8
Security incident Any incident to the following Equipment security The protection of Trust equipment, drugs and assets in order to prevent loss, theft or abuse by any person Premises security The protection of Trust premises in order to prevent damage or theft by any person Vehicle The protection of Trust owned /leased / borrowed / rented vehicles in order to prevent loss, theft or damage by any person Self harm behaviour Slip/Trip/Fall Drug Security The protection of drugs held on behalf of the Trust, including the safe storage, issue and disposal, to prevent loss, theft or misuse by any person. Self-injury (SI), also referred to as self-harm (SH), self-inflicted violence (SIV) or self-injurious behaviour (SIB), refers to a spectrum of behaviours where demonstrable injury is self-inflicted Slip: The mechanism of slipping can be broadly categorised as follows: The heel of the moving foot contacts the surface and slips forward, or The heel of the rear foot lifts as the force moves towards the front of the foot, the sole slips backwards and the person falls forwards Trip: Incidents that relate to a Trip due to obstructions on the floor surface (clutter and debris), fixed or otherwise, or when a person s view of obstructions is impeded or obscured. Falls can be classified into four categories: 1. Trip-and-fall accidents, in which pedestrians encounter a foreign object in their walking path; 2. Stump-and-fall accidents, in which a moving foot encounters an impediment in the walking surface, whether it is a tacky point on the surface or a defect that impedes the foot; 3. Step-and-fall accidents, in which the foot finds an unexpected failure or hole in the walking surface 4. Fall accidents, in which the interface of the shoe and the floor fails to support the walker's center of gravity over the base area NWAS: Incident report form IRF Page: 7 Of 8
Staff Injury Third Party Injury Theft Verbal abuse Any incident where by a member staff of receives an injury whilst on duty in the NWAS Any incident where by a member of the public not in the care of the NWAS receives an injury involving the Ambulance Service. A person is guilty of theft if he dishonestly appropriates property belonging to another with the intention of permanently depriving the other of it The use of inappropriate words or behaviour causing distress and/or constituting harassment Useful Links HSE online:- www.hse.gov.uk HSE books:- www.hsebooks.co.uk HSE Infoline:- Tel: 0845 345 0055 To contact your local Risk and Safety Department see separate NWAS Risk and Safety Team contact list. NWAS: Incident report form IRF Page: 8 Of 8