BRADFORD & AIREDALE CCG TRUST

ashcroft surgery,
bradford

Newlands Way, Eccleshill, Bradford, BD10 0JE, West Yorkshire, UK

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Serious Untoward Incidents – reporting & risk management

Downloads

  • – – –

ASHCROFT LEADS

  • Doctor:   Dr Sudhir Krishnan
  • Nurse: – 
  • Admin:  Chris Rushton 

DATE REVIEWED:

20th June 2019

DATE OF NEXT REVIEW:

June 2020

Intro

Risk Management has been defined as the culture, processes and structures that are directed towards the effective management of potential opportunities and adverse effects. The practice is working with and continuing to develop an integrated Risk Management system, covering both clinical and non-clinical activities, which will significantly help the practice to meet its business objectives in a manner consistent with public interest, safety and the law.

Incident reporting is a fundamental tool of risk management…
The aim of incident reporting is to assist in the management of adverse incidents, including near misses and hazards, and to collect information about incidents which will help to facilitate wider organisational learning. If incidents are not properly managed, they may result in a loss of public confidence in the organisation and a loss of assets. The GP partners and manager have made their support for patient and staff safety transparent by their actions in supporting the Risk Management Strategy and related polices including this policy and it is clearly understood throughout the organisation that it is unacceptable to reach other objectives at the expense of safety.

Purpose of this Protocol

The purpose of this policy is to inform and guide staff on how to report and manage incidents. It is the practice’s intention to appropriately manage and investigate incidents, based on their severity, and to ultimately learn and make changes as a result of incidents in order to improve safety, for patients, staff, visitors and contractors and to share these lessons within the practice and more widely across healthcare, as appropriate.

  • Personal accident
    Any accident, no matter how small, that did or could have adversely affected any person.
  • Physical assaults
    Any incident involving a physical assault, whether or not injury results. The incident report should include details of whether the Police were involved, including any Crime Reference Number.
  • Non-physical assaults
    Any incident involving verbal abuse, verbal threats, unsociable behaviour, racial or sexual harassment, brandishing of objects or weapons. The incident report should include details of whether the Police were involved, including Crime Number.
  • Ill health
    Any case, known or suspected of work or work environment related ill health (e.g. blood borne infection, dermatitis, latex allergy, etc.).
  • Clinical incident or serious untoward incident|
    An event or omission arising during clinical care causing physical or psychological injury to a patient (e.g. treatment error, drug error, equipment failure). Unexpected deaths, this includes suicides, homicides and drug incidents such as overdoses.
  • Medical device(s) failures
    Any untoward incident involving medical devices (e.g. hoists, wheelchairs, cot sides or bed rails, blood pressure monitors, syringe drivers, etc.).
  • Near miss: ‘Clinical’
    Any act of commission or omission, arising during an episode of clinical care, which may have resulted in injury or damage to a patient, but where the adverse outcome was prevented.
  • Near miss: ‘Non-clinical’
    Any non-clinical near miss where under different circumstances the person involved could have received personal injury or there could have been property damage/loss.
  • Fire incident
  • Any incident, no matter how small, involving fire or fire warning systems (including accidental and deliberate false alarms). The incident report should include details of whether the building was, evacuated and if the fire brigade were in attendance.
  • Security incident
    Any untoward incident involving theft, loss or damage to practice or personal property e.g. ID badges and security passes, intrusions, false alarms (but not fire alarms), and other security incidents. The incident report should include details of whether the Police were involved, including any Crime Number.
  • Vehicle incident
    Any incident involving a vehicle (e.g. road traffic accident during work related activities) excluding vandalism or theft that would be classified as a security incident. The incident report should include details of whether the Police were involved, including any Crime Reference Number.

The Protocol

  • The practice uses a template within systmone (significant event) to record that will be reviewed at meetings. A printed copy must also be given to the manager.
  • A Guide to information which must be included in all incident reports is shown at Appendix 2. Reporting of incidents can help to identify common trends, hence need to change systems, policies and procedures to lesson the risk of reoccurrence.
  • If needle stick, then also see specific policy – infectious diseases.

Things to do

When an incident occurs staff members should report them to their immediate line manager as soon as possible. The urgency of reporting should be linked to the severity of the incident but the incident should be reported within a maximum of one working day. If the incident is very severe it is vital that verbal contact be made with the line manager or a practice partner as quickly as possible. Staff members should then complete an incident report form.

First of all, make things safe

Then Document 

  • Document the incident on the dummy patient “Mr Significant Event” in SystmOne
  • ALSO – fill out accident book in surgery post room.
  • Inform the Practice Manager

The line manager ensures that:-

  • any immediate actions have been completed and noted on the incident report form.
  • any further documentation which is needed has been completed.
  • the incident form has been completed properly by the staff member by checking the grading of the incident is appropriate, and by completing the details of “Management Responsibility” on the form.
  • Anyone else within the organisation that needs to know about the incident.
  • Communication with other relevant stakeholders such as patients and/or the relatives, visitors or contractors has been undertaken.
  • Investigation of the incident including creation of an action plan and lessons learnt to be shared in the organisation, (appropriate to the level of severity of the incident being reported) has been carried out.
  • Reports to external bodies are completed in a timely manner e.g. RIDDOR, PARS, MHRA. See External Reporting of Incident (5.2)

Investigation of incidents will be related to the severity. As a rule of thumb, incidents which are graded as Severe will denote high risks which will necessitate further investigation. All incidents that are graded Red will constitute a Serious Untoward Incident (SUI).

Incidents which are graded as low risk can be investigated with a proportional amount of effort from staff and managers. However, there may be Incidents which are graded as low risk that, from time to time, need to be investigated. This may happen if incidents of one type are occurring regularly or are part of a theme or trend drawn out from the analysis of all incidents, which are carried out by the CCG Risk Manager (Adverse Events). It is important that these themes, where they apply to Provider arm services, are shared within the Provider arm (either with the Safety and Care Governance Group and/or appropriate Heads of Service) before these are shared with the Quality, Safety and Governance Group or other practice groups.

The level of details of action planning following on from an incident should be proportionate to the severity of the incident being investigated. Where it is appropriate for action plans to be created these should also include details of the person responsible for the action and an expected completion date. Action Plans should also include a section for reflection to highlight any lessons learned from the adverse event and the actions taken. Copies of these can be sent to the risk management team so that any changes to system that may have an impact on other parts of the organisation can be identified.

Monitoring of action plans

If risks remain from serious incidents these should be added, along with appropriate actions to the Assurance Framework. The actions and ongoing risk levels should then be monitored through the Assurance Framework. The actions plans arising from less serious incidents, or those where the residual risk is low should be monitored locally through the management structure.

Sharing of lessons learnt

The sharing of the lessons learnt post investigation is a critical part of incident management and these should be shared as appropriate. As a minimum these should be raised at meetings of the team where the initial incident occurred.

Frequently Asked Questions (FAQs)

  • RIDDOR A RIDDOR incident relates to the items reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
  • STEIS Strategic Executive Information System – this is the CCGs mechanism for reporting serious untoward incidents to the West Yorkshire Strategic Health Authority (WYStHA).
  • PARS A PARS incident relates to the incidences of physical assault which are to be reported on PARS (Physical Assault Reporting System)
  • MHRA Incidents involving medical devices are reportable in some circumstances to the Medicines and Healthcare products Regulatory Agency (MHRA)

REPORTING INCIDENTS TO THE NATIONAL PATIENT SAFETY AGENCY (NPSA), RIDDOR OR MHRA

By completing the incident reporting form, staff agree to this information being shared with the National Patient Safety Agency (NPSA) via the National Reporting and Learning System (NRLS).

Manager/partners need to notify the Health & Safety Executive (HSE) if the incident is RIDDOR reportable. (Reporting of Injuries, Diseases or Dangerous Occurrences Regulations) and the Risk Manager (Health & Safety), or the Health and Safety Manager, should be informed as soon as possible and provided with a copy of the completed RIDDOR report.

The practice has a duty to report adverse incidents involving a device to the MHRA if the incident has led to, or were it to occur again, could lead to:

  • Death or life-threatening illness or injury
  • Deterioration in health
  • The necessity for medical or surgical intervention
  • Unreliable test results leading to inappropriate diagnosis or therapy

It is the responsibility of the line manager/clinician to ensure that these types of incidents are reported to the MHRA. The MHRA should also be informed by the line manager of any other device related minor faults or discrepancies, since they may take on a greater significance when aggregated with other similar events or may be indicators of inadequate quality assurance by the manufacturer or supplier.

The MHRA should also be informed of adverse incidents even if they are caused by human error. (MHRA website)

The practice strives to encourage a climate of openness and dialogue where staff feel free to raise their concerns and work towards a mutually acceptable resolution. Where staff members feel that this is not appropriate, they may use the whistle-blowing policy, which provides a safe framework within which concerns can be raised without fear of discrimination, victimisation or reprisals. The whistle-blowing procedure is primarily for concerns where the interests of others or of the organisation itself are at risk. (see Whistle-blowing policy)

Communication with the patients and/or the relatives, visitors or contractors may be needed both pre and post investigation. In nearly all cases this should happen as close to the incident as possible, and by the most appropriate member of staff. The importance of recording this communication in appropriate documentation is stressed. This communication may include information regarding any support systems which are available to patients/relatives/visitor/contractors.

This communication needs to follow the principles of ‘being open’. If people are raising

a concern then it is important that reference to how to make a complaint is made.

In cases where there is likely to be media interest, it is important to inform patient/staff/relatives and other persons (i.e. contractors involved in or affected by the event) before the media. The communications team based at Douglas Mill will be tasked with dealing with and co-ordinating such media communications; information should be given to the communications team as soon as possible so they are prepared should they be contacted by the media.

  • Incident
    ‘any event, untoward or unusual, which is a deviation from the normal pattern of activity or therapeutic well-being or smooth running of the workplace (e.g. health centre, department, client’s home, etc.), which involves patients and/or staff and/or visitors, and which may adversely affect their health and/or safety and/or welfare then or later’.
  • Serious untoward incident (SUI)
    ‘any accident or incident where a patient, member of staff, or member of the public suffers serious injury, major permanent harm or unexpected death, (or the risk of death or injury), on health service premises or other premises where health care is provided, or where actions of health services staff are likely to cause significant concern’.
  • Near miss
    ‘any incident that did not lead to harm, but could have led to harm under different circumstances’.
  • Examples: Delay in diagnosis, wrong diagnosis, or incorrect patient assessment; Administration of the wrong drug, or wrong dose of the correct drug; Mistakes made due to failures in communication; Failure of medical devices; Wrong procedure carried out; Accidental injury to a patient during procedure; Failure to act on important information.
  • Harm
    ‘any injury (physical or psychological), disease, suffering, disability or death’.
  • In most circumstances, harm can be considered to be unexpected if it is not related to the natural cause of the patient’s illness or underlying condition.
  • Hazard
    something with the potential to cause harm, or adverse effect on the health of people. Anything, which may cause harm, through injury or ill health, to anyone at or near a workplace, is a hazard. While some hazards are fairly obvious and easy to identify (e.g. trailing wires, wet floors), others are not – for example exposure to noise, hazardous chemicals or blood-borne viruses.
  • Risk
    is the probability/likelihood of harm actually occurring (e.g. almost certain, likely, possible, unlikely, rare) and the impact/severity of the harm (e.g. catastrophic, major, moderate, minor, insignificant). The level of risk to health increases with the impact/severity of the hazard and the duration and frequency of exposure to the hazard.
  • Adverse event
    ‘any incident that did lead to harm’.
  • Accident
    ‘any unplanned event that results in injury or ill health of people, or damage or loss of property, plant, materials or the environment, or the loss of business opportunity’.
  • Physical assault
    ‘the intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort’.
  • Non-physical assault
    ‘the use of inappropriate words or behaviour causing distress and/or constituting harassment’

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