The Management of Significant Adverse Events in NHS

The Management of Significant Adverse Events in NHS Ayrshire & Arran – June 20123.4 Investigation and Reporting Timelines55 The Adverse Event Policy and Supporting Procedures states that any:“members of staff who have knowledge of or has been directly involved in an adverseevent, must complete a report utilising the current risk management system, within 24hours” (see paragraph 4.10).56 In a few instances, substantial delays between the date of incident and reportingreflected the fact that the actual incident had taken place a significant period before thedate that the actual incident became known to NHS Ayrshire & Arran (for example, a‘missed diagnosis’ which goes unnoticed and only comes to light many months later).However, in other instances there are delays which are not accounted for by this reason.Tables 1–6 provide an analysis of investigation reporting timelines.Table 1: Seven sample cases - performance against 24-hour target (length of time,in days, between the incident occurring and the incident being reported on Datix)Case numberIncident occurring to incident beingreported on Datix (days)1 (v) 52* Same/next day3* 34 (v) 25* 96* Same/next day7* 522 (misdiagnosis case)(v) = verified dates against Datix records*Datix record not provided to verify date and no time information supplied to calculate 24 hour targetTable 2: 57 significant adverse event review cases - performance against 24-hourtarget (length of time, in days, between the incident occurring and the incidentbeing reported on Datix)Same/Nextday2 to 4 days 5 to 7 Days 8+ days Missing Negativedays*17 (29.8%) 12 (21%) 3 (5.3%) 21 (36.8%) 3 (5.3%) 1 (1.8%)*The reference to ‘negative days’ relates to the incident being presumably mis-recorded as happeningafter the date of reporting.22