Session 3 - Incident Reporting Policy - Health Partnerships Learning ...

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Ward closure Child death Serious sexual assault Risk to NCH’s reputation; and Infection outbreaks Significant loss of confidential information or patient identifiable information Staff: ‘Staff, volunteers, students and sub-contractors working for Nottinghamshire Community Health and independent contractors commissioned by NCH. 4 Duties Managing Director: The Managing Director has overall responsibility for risk management within NCH Assistant Directors/Associate Directors Ensure all staff in their Directorate are informed of the need to report incidents which arise out of the activities of the Directorate Ensure all directly employed staff understand the incident reporting system and receive feedback from incidents reported Ensure contractors and volunteers are aware of the Incident Reporting Policy Allocate sufficient resources (both financial and human) for incident investigation and follow up Ensure any recommendations made as a result of investigations are put into place Locality Service Managers/Heads of Service Ensure all staff, bank staff, agency workers and contractors under their control understand and follow this policy accordingly Ensure that all incidents within their sphere of responsibility are reported Grading all accidents as soon as possible in accordance with the Matrix in this policy. (See How to Report an Incident or Near Miss Appendix A) Liaise with Occupational Health team regarding any health issues related to the health of the injured person Report intentional assault on staff to the Risk Management Team; who will report to the Local Security Management Specialist (LSMS) Officer Ensure that all incidents classified as Major or above are reported immediately to the Risk Management Team based at Ransom Hall Ensure that all other incidents are reported to the Risk Management Team within 24 hours of the incident occurring or 1 working day Undertake investigation as appropriate and completion of the manager’s action section of the incident report form and returned to the Risk Management team based at Ransom Hall within 2 weeks from the date of the incident. Ensure recommendations and actions are carried out as a result of any investigation Monitor information reported on the incident forms for accuracy and completeness Ensure that any procedures within their area take account of incidents which have been brought to their attention Ensure that serious incidents are brought to the immediate attention of their Line Manager or Assistant Director Where appropriate obtain witness statements Make safe any area or equipment following an accident and retaining equipment for inspection where required Page 6 of 28
Ensure that risk assessments are reviewed or carried out on all significant identified hazards and appropriate action plans put in place to reduce risks to an acceptable level. The results of those risk assessments must be communicated to all those who may be at risk Provide feedback to directly employed staff on trends, serious incidents, results of investigations, recommendations and any learning opportunities Risk Manager/Health, Safety & Risk Facilitator/Risk Management Team must: Collate, review and support managers with incidents reported Support local managers in the investigation process (to be decided case by case) on incidents Compile quarterly summary reports on incidents and review recorded incidents to identify trends Ensure that all reports are anonymised so that patients cannot be identified from them Bring any incidents or trends of particular importance or giving rise to immediate concern to the attention of the Assistant Director of Professions and Governance, Head of Governance & Compliance and/or the appropriate Assistant Director Ensure lessons learned are cascaded and embedded in practice. This will be done through discussion in team meetings, training, newsletter, posters and intranet Highlight NCH wide incident trends to the staff and Committees as required on a quarterly basis, or more frequently if required Ensure aggregated qualitative and quantitative data on incidents is produced within the quarterly incident reports. The qualitative data will include types and number of incidents, service affected, risk severity comparison with previous quarter Ensure that all reports do not contain any information that would allow the patient to be identified Ensure any risk discovered from trends and themes in the aggregated data is transferred into the appropriate risk register. Ensure the NCH audit program is informed of risks to enable adaptation to encompass auditing of learning within the agreed timeframe to ensure staff alter their practice in response to lessons learnt Ensure information related to NCH performance in relation to numbers of incidents and trend analysis are presented to the appropriate Committee, raise awareness of activity and to engage in the processes of organisation wide learning and development Ensure that lessons learnt from trend analysis result in a change in organisational culture and practice through a robust risk register process Ensure lessons learned are cascaded and embedded in practice. This will be done through discussion in team meetings, training, newsletter, posters and internet and the National Patient Safety Agency (NPSA) Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) accidents/incidents to the Health and Safety Executive (HSE) Ensure that accidents/incidents are appropriately investigated, and where necessary remedial measures taken Maintain an appropriate filing system for hard copy incident report forms Produce collated reports on incidents for the Health and Safety Group Forward all incidents of intentional assault and verbal abuse to the Local Security Management Specialist (LSMS) Report details of patient related incidents to the NPSA under the National Reporting and Learning System (NRLS) Page 7 of 28
Page 1 and 2: Incident Reporting Policy Reader in
Page 3 and 4: 1 Introduction The effective report
Page 5: Other incidents: Some incidents may
Page 9 and 10: Following a reported incident, rega
Page 11 and 12: Incident Reporting Folders (a compl
Page 13 and 14: All Action Plans relating to incide
Page 15 and 16: Department of Health. (2000). An Or
Page 17 and 18: Guidance on completing an Incident
Page 19 and 20: SECTION 10 (S10) PART 2 IS TO BE CO
Page 21 and 22: Risk Matrix - Severity 1 2 3 4 5 De
Page 23 and 24: Appendix D DEFINITIONS OF SERIOUS U
Page 25 and 26: Appendix E SENIOR MANAGER ON-CALL A
Page 27 and 28: Appendix G Plan for Dissemination o

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