Serious Untoward Incidents – reporting & risk management

Practice Leads

  • Doctors: Sudhir Krishnan
  • Nurse: Zoe Booth
  • Admin: Chris Rushton

Date Reviewed

6th August 2016

Date of Next Review

September 2017

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 policy

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.

Process for reporting

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 a reoccurrence.

If needle stick, then also see specific policy - infectious diseases.

What to do - role of affected/involved staff member

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.

Role of line 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)

REPORTING must do’s:-

  • fill out electronic form on Systmone (via pt Mr Significant Event)
  • print out a copy of completed template form and give to the
  • If injury – get treatment from doctor/nurse.

MUST - Fill out accident book in surgery post room.

  • Needle stick injuries also have own protocol that includes occupational health.

Reporting and Management Procedure

  • 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)

Investigating the Incident

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.

Action Plan & Sharing Lessons Learnt

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.

Some Definitions

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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