Serious Untoward Incident Policy - Health Partnerships Learning ...

Main report Headings:3 Relevant documentation [anonymised]4 Photographs [where relevant with appropriate consent]5 Personal accounts / statements [anonymised]6 Root Cause Analysis tool used [E.G. Completed Time line / fishbone]7 Action Plan with identified lead individualsFree text narrative of the entire adverse event related to appropriate appendices.1.0 The Adverse Event:Very Brief synopsis of what happened, the headlines:- Adverse Event Report [AER]number (used to link all relevant information) Date, Time, Location.2.0 Background:Factors leading up to the event Clinical history where relevant Setting the context3.0 The occurrence of the event:Detailed Chronology / Factual account / no speculation4.0 Immediate actions:How the event was initially managed: patient / staff safety / preservation of the scene/ who was informed [role / job title not personal names]5.0 Contributory Factors / Root Causes:Describe Root Cause methodology:[See NPSA toolkit at: http://www.npsa.nhs.uk/health/resources/root_cause_analysis]Include as appendix one of completed Time line / fish bone, five whys etc.Use the following headings for narrative: Environment / working conditions: Task / process: Equipment and resources: Patient factors: Staff / Team factors: Communication Factors: Organisation / Strategic / Management factors: Exterior influences: local / national6.0 Potential long-term outcomes:[Future risk: consequences & likelihood]For those involvedFor the organisation7.0 Conclusion:Include principal root causes8.0 Recommendations:To form basis of action plan9.0 Action Plan:What is to be done, by whom and by when.31